Escolar Documentos
Profissional Documentos
Cultura Documentos
Table of Contents
1.0
2.0
3.0
Introduction....................................................................................................... 15
4.0
3.1
3.2
3.3
3.4
3.5
3.6
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
6.0
6.2
6.3
6.4
Page 2
7.0
8.0
8.2
8.3
Page 3
Table of Figures
Figure 1: New VCP Report Outline. ................................................................................ 13
Figure 2: Continuum of Care Coordination. .................................................................... 22
Figure 3: Care Coordination Experience Based on Veterans PCP Choice. ................... 24
Figure 4: System of Systems Approach for the New VCP .............................................. 32
Figure 5: High-Performing Network Model...................................................................... 57
Figure 6: Diagram of Medium- and Long-Term Improvements for Health Information
Management .................................................................................................. 71
Figure 7: Phased Approach to the New VCP.................................................................. 74
Page 4
Table of Tables
Table 1: Impact of the Single Program for Non-Department Care Delivery .................. 35
Table 2: Current-State Eligibility CriteriaHospital Care, Medical Services, and
Dentistry ......................................................................................................... 38
Table 3: Current-State Eligibility CriteriaEmergency Treatment ................................ 39
Table 4: Future-State Eligibility CriteriaHospital Care and Medical Services ............ 42
Table 5: Future-State Eligibility CriteriaEmergency Treatment and Urgent Care ...... 43
Table 6: Impact of the Patient Eligibility Requirements ................................................. 44
Table 7: Referral and Authorization Definitions ............................................................ 45
Table 8: Impact of Authorizations ................................................................................. 47
Table 9: Impact of Billing and Reimbursement ............................................................. 50
Table 10: Impact of Provider Reimbursement Rate ........................................................ 53
Table 11: Key Elements of the High-Performing Network .............................................. 57
Table 12: High-Level Provider Credentialing Standards ................................................. 59
Table 13: Impact of Provider Eligibility ............................................................................ 60
Table 14: Impact of Prompt Payment Compliance ......................................................... 62
Table 15: Impact of Network and Infrastructure .............................................................. 65
Table 16: Current-State Limitations for Health Information Management ....................... 68
Table 17: Near-Term Improvements for Health Information Management ..................... 69
Table 18: Medium & Long Term Improvements for Health Information Management .... 70
Table 19: Impact of Medical Records Management Requirements ................................ 71
Table 20: Alignment of New VCP Functional Areas to Component Systems ................. 73
Table 21: New VCP Transition Risks .............................................................................. 83
Table 22: Estimated Incremental Costs for New VCP System Redesign & Solutions .... 89
Table 23: Estimated Incremental Costs for New VCP Hospital Care and Medical
Services Eligibility Changes ........................................................................... 90
Table 24: Estimated Incremental Costs for New VCP Emergency Treatment Changes. 91
Table 25: Summary of Legislative Proposals................................................................ 102
Table 26: VAs General Contracting Authorities for Health Care .................................. 104
Table 27: VAs Authority to Reimburse for Community Care ........................................ 106
Table 28: VAs Community Care Programs .................................................................. 107
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Table 29: VAs Benefit Programs to Provide Services to Veterans, Survivors, and
Dependents .................................................................................................. 108
Table 30: VAs Authority to Furnish Specific Services by Community Providers .......... 109
Table 31: Alignment with Independent Assessment Report Recommendations........... 118
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1.0
Executive Summary
The New VCP will clarify eligibility requirements, build on existing infrastructure to
develop a high-performing network, streamline clinical and administrative processes,
and implement a continuum of care coordination services. Clear guidelines,
infrastructure, and processes to meet VAs community care needs will improve
Veterans experience and access to health care. VAs future health care delivery
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network will address gaps in Veterans access to health care in a simple, streamlined,
effective manner and will continue to support VAs missions of research and education.
VA is continuing to examine how the Veterans Choice Program interacts with other VA
health programs, including the delivery of direct care. In addition, VA is evaluating how
it will adapt to a rapidly changing health care environment and how it will interact with
other health providers and insurers. As VA continues to refine its health care delivery
model, we look forward to providing more detail on how to convert the principles
outlined in this plan into an executable, fiscally-sustainable future state. In addition, we
plan to receive and potentially incorporate recommendations from the Commission on
Care and other stakeholders.
VA anticipates improving the delivery of community care through incremental
improvements as outlined in this plan, building on certain provisions of the Veterans
Choice Program. The implementation of these improvements requires balancing care
provided at VA facilities and in the community, and addressing increasing health care
costs. VA will work with Congress and the Administration to refine the approach
described in this plan, with the goal of improving Veterans health outcomes and
experience, as well as maximizing the quality, efficiency, and sustainability of VAs
health programs.
Establish a single set of eligibility criteria for all community care based on
geographic access/distance to a VA primary care provider (PCP), wait-time for
care, and availability of services at VA.
Expand access to emergency treatment and urgent community care.
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Page 9
The New VCP will use a system of systems approach to enhance these five functional
areas as part of the larger VA health care transformation. This approach stresses the
interactive, interdependent, and interoperable nature of external and internal
components within VAs health care delivery system. The New VCP includes
enhancements to the following systems, which will have a positive impact on VA and
the greater Veterans health ecosystem:
The New VCP plan envisions a three-phased approach to implement these changes to
support improved health care delivery, as outlined in the Transition Plan (Legislative
Element 10). This will deliver incremental improvements while planning for a future
state consistent with evolving health care best practices. The first phase will include
development of the implementation plan and will focus on the development of minimum
viable systems and processes that can meet critical Veteran needs without major
changes to supporting technology or organizations. Phase II will consist of
implementing interfaced systems and community care process changes. Finally, Phase
III will include the deployment of integrated systems, maintenance and enhancement of
the high-performing network, data-driven processes, and quality improvements.
Executing the New VCP will not be possible without approval of requested legislative
changes and requested budget. The primary objectives of the legislative proposal
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Conclusion
Transformation of VAs community care program will address gaps in Veterans access
to health care in a simple, streamlined, and effective manner. This transformation will
require a systems approach, taking into account the interdependent nature of external
and internal factors involved in VAs health care system. MyVA will guide overall
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improvements to VAs culture, processes, and capabilities and the New VCP will serve
as a central component of this transformation. The successful implementation of the
New VCP will require new legislative authorities and additional resources and will
position VA to improve access to care, expand and strengthen relationships with
community providers, operate more efficiently, and improve the Veteran experience.
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2.0
Each section of this report (Figure 1) directly addresses the legislative elements set
forth in the VA Budget and Choice Improvement Act, Plan to Consolidate Care in the
Community Programs of the Department of Veterans Affairs to Improve Access to Care,
in the VA Budget and Choice Improvement Act and discusses in detail the key
enhancements that will eventually shape the future of VA health care delivery.
Introduction: The introduction outlines the future of VAs health care delivery and
includes the stated objectives of the New VCP in the larger context of the VA
delivery system, including enhancements to care coordination, and how these
enhancements align with MyVA.
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3.0
Introduction
VA is committed to providing Veterans accessible, timely, and high-quality care with the
utmost dignity and respect. At the heart of this mission is a commitment to improving
performance, promoting a positive culture of service, increasing operational
effectiveness and accountability, advancing health care innovation through research,
and training future clinicians.
Health care delivery models must adapt and evolve to meet the needs of patients.
Overall, the U.S. health care system is changing significantly with regard to the types of
care demanded and the way patients seek care. New technologies are drastically
changing how patients access care and how providers and patients interact.
Innovations in precision medicine, telehealth, value-based care models, genomics, and
overall operational efficiency represent only some of the trends in U.S. health care over
the last several years.
VA is evolving to meet the distinct needs of Veterans, driven by aging and an increased
number returning from war with mental and physical conditions unique to service, 1 while
also adapting to broader health care trends. Over the last several decades, VA has
seen an increase in demand for primary and preventive care and a decrease in demand
for hospital-centric inpatient care. In 2016, VA estimates that there will be more than
101million outpatient visits annually, an increase of 2.8 million visits per year from
2015. 2 Furthermore, the number of women Veterans requesting health care from VA
has increased by 80 percent over the last decade, meaning VA is experiencing a
greater demand for care and services that have not been traditionally provided at VA
facilities (e.g., obstetrics and mammography). The lack of available services at VA
facilities means that women Veterans must seek community care. In fact, women
Veterans are more than twice as likely as men to receive community care. 3
As the health care landscape changes, VA understands that its health care delivery
system must also change to better meet the evolving needs of Veterans. In August
2014, Congress enacted The Choice Act, which required VA to establish the Veterans
Choice Program to address VAs health care access challenges. The Veterans Choice
Program became an additional method for VA to purchase community care, but added
complexity and confusion for Veterans, VA staff, and community providers.
The Critical Need for Military & Civilian Mental Health Professionals Trained to Treat Post Traumatic
Stress Disorder & Traumatic brain Injury. http://www.apa.org. Accessed October 5, 2015.
http://www.apa.org/about/gr/issues/military/critical-need.aspx.
2 United States. Cong. Senate. Committee on Appropriations Subcommittee on Military Construction,
Veterans Affairs, and Related Agencies. Budget Request for Fiscal Year 2016, Apr. 21, 2015. 114th
Cong. 1st sess. Washington: GPO, 2005 (statement of The Honorable Robert A. McDonald, Secretary,
Department of Veterans Affairs).
3 Sourcebook Vol. 3 - Part 4: Non-VA (Fee) Medical Care Utilization, FY12
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VAs future health care delivery system must address Veterans access to health care in
a simple, streamlined, and effective manner. Veterans should receive uniformly highquality care, whether at VA or in the community. The future VA health care delivery
system must operate more efficiently, better adopt technological advances, and develop
and maintain relationships with strategic partners to support an equitable experience
inside and outside of VA. To reach this desired state, VA plans to use a system of
systems approach that will address the enterprise-wide challenges in meeting the
unique needs of Veterans.
3.1
Stakeholder Feedback
Continue to provide a unique environment and culture for Veterans health care
Recognize that some Veterans are willing to travel farther to see their VA provider
Clarify processes for accessing community care, as current processes are confusing
Address concerns that the current VA provider system would be underfunded to
purchase community care
Be the face of care coordination for Veterans
Streamline emergency treatment regulations, processes, and procedures, which are
complex, inconsistently applied across Veterans Health Administration (VHA), and
cause significant confusion for VA staff, Veterans, and community care providers
VA Staff and Clinicians: VA staff and clinicians work hard to serve Veterans every
day; however, they need additional support. Feedback from the field identified the
following themes:
Retain elements of the non-VA care program that worked well and relationships that
were effective prior to the Veterans Choice Program and can be used as best
practices
VA and Congress should articulate a clear strategy governing the use of purchased care. Independent
Assessments C. Care Authorities
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Federal Partners: Discussions with DoD, OMB, agencies of the Department of Health
and Human Services (HHS), including the Centers for Medicare and Medicaid Services
(CMS), the Health Resources and Services Administration (HRSA), and the IHS yielded
the following themes:
Tribal Consultation: Tribes from around the country were given the opportunity to
provide feedback about the role of IHS and THP in the VA health care system, as well
as VAs efforts to streamline the provision of non-VA care to Veterans. Responding
tribes indicated the following:
Strong support for the inclusion of IHS and THP as key partners in VAs community
network.
Maintain and strengthen the current agreements between VA, the IHS, and THPs.
Interest from IHS and THPs in potentially serving non-Native Veterans.
Health Care Industry Leaders: Leaders from across the health care industry, focusing
on health plan capabilities and integration with a provider organization, raised the
following themes regarding best practices and opportunities for a future VA community
care program:
Adopt best practices in clinical and administrative decision making by using data on
the needs of Veterans and metrics on the quality of providers
Build a sound technology infrastructure and utilize new technologies and predictive
analytics to optimize health outcomes and enhance Veterans experience
Lead in the field of care coordination
Provide the care and services Veterans require through a high-performing network
Along with extensive input from across VA, these stakeholders helped identify key
requirements for the future of VA health care, of which the New VCP is one component.
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3.2
As the health care landscape and the needs of Veterans change, VAs health care
delivery model must also change. Historically, VAs identity has been a hospital-based
provider organization. This delivery model is evolving into team-based care delivered in
a variety of settings, including virtual- and home-based care. Simultaneously, VA is
increasingly becoming a larger purchaser of care, in addition to being a provider. VA
will focus on the following set of guiding principles to direct the evolution of VA health
care delivery:
Invest in and grow VAs core competencies. In a transformation such as this,
organizations must make decisions about where to invest resources. No organization
can excel at every capability; high-performing organizations define their core
competencies and excel at those. Service delivery systems designed around core
competencies distinguish organizations from others and provide the highest potential
value to their customers. VA establishes a relationship with Veterans as they transition
out of military service. Unlike commercial health plans, where beneficiaries change
plans periodically and disrupt continuity of care, Veterans are Veterans for life. This
transformation is both a unique opportunity and responsibility for VA to address
Veterans health care more holistically. As VA continues to optimize its health care
delivery system, it is important to continue to focus on areas of critical need to Veterans,
as well as where there are gaps in private sector care (e.g., service-related injuries,
traumatic brain injuries (TBI), post-traumatic stress disorder, and integrated mental
health).
Maintain a high-performing network to deliver care. A high-performing network
refers to an ecosystem of health care providers that optimize the health of beneficiaries
and operational efficiencies. High-performing networks deliver patient-centered care,
are comprised of high-performing providers, monitor quality, incentivize clinicians
through innovative reimbursement models, use
High-performing Network Enablers
data to adapt services, and create a better
environment for customers. High-performing
Performance and
experience. 5 As part of a high-performing network,
outcomes-based metrics
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evolving health care landscape and adopt new technologies, but should also recognize
that current methods for measuring success in this area may be limited.
Consistent with the Independent Assessment Report, VA plans to employ a system of
systems approach for the development, deployment, long-term oversight, and
coordination of health care delivery. 7 This is defined as The design, deployment,
operation, and transformation of metasystems that must function as an integrated
complex system to produce desirable results. These metasystems are themselves
composed of multiple autonomous embedded complex systems that can be diverse in
technology, context, operation, geography, and conceptual frame. 8 This recognizes
that systems are constructed from components and optimization of a single component
may negatively affect others.
In this report, we identify requirements of five systems necessary to VA health care and
the New VCP:
1. Integrated Customer Service Systems
2. Integrated Care Coordination Systems
3. Integrated Administrative Systems (Eligibility, Patient Referral, Authorization, and
Billing and Reimbursement)
4. High-Performing Network Management Systems
5. Integrated Operations Systems (Enterprise Governance, Analytics, and Reporting)
Some components of these systems already exist at VA. For these systems to work
together seamlessly with care provided at VA and non-VA facilities, they must be
designed as a system of systems. From that perspective, while the elements of this
report focus on the purchase of community care, the development of a high-performing
network cannot occur without addressing both care delivery by VA providers and care
purchased in the community. Therefore, in addressing systems supporting the
purchase of community care, VA must ensure that these systems are fully integrated
with those supporting Veterans care within VA.
Care coordination is critical to support the delivery of VA health care as Veterans
access care at VA facilities, virtually, and in the community. The relationship of the
Veteran (and caregivers) to his or her primary care team is central to coordination.
Care coordination, however, is not a one-size-fits-all model; it occurs on a spectrum. As
a Veterans needs evolve, VA will need to tailor care coordination to each situation.
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3.3
Care Coordination
VA can be a leader in care coordination. While this is a broad term with a variety of
interpretations in health care, the Agency for Healthcare Research and Quality (AHRQ)
states that, care coordination involves deliberately organizing patient care activities and
sharing information among all of the participants concerned with a patient's care to
achieve safer and more effective care. This means that the patients needs and
preferences are known ahead of time and communicated at the right time to the right
people, and that this information is used to provide safe, appropriate, and effective care
to the patient. 9 The goal of care coordination is to meet patient needs and deliver highquality, high-value care from the perspectives of the patient and family, provider team,
and the health system. Care coordination should improve health outcomes, prevent
gaps caused by transition of setting or time, and support a positive and engaging patient
experience.
Operationally, care coordination is a team-based activity that includes the patient,
family, caregivers, staff, and clinicians. Each part of the team has different needs for
services and information (clinical and administrative) during a transition of care, such as
referral to a specialist, hospital discharge, or a period of time between clinical visits. In
the example of a referral, a PCP and a patient decide to seek the input of a specialist on
a specific condition. The patient and caregivers need to know how to choose a
provider, what to do before the visit, when to go, and how to follow up appropriately.
The primary care team needs to communicate clinical information to the specialist;
understand when the visit has occurred; what the diagnosis was; and how to support
any subsequent care plan. VA staff need to know how to help patients and caregivers
to schedule and attend the appointment and how to direct appropriate information to the
team. For this transition to be seamless, all parties need access to systems that supply
accurate, timely information, workflows that address the needs of the team members,
and metrics to understand the success of these interactions. As a result, care
coordination is complex and information intensive, requiring a cohesive approach.
While this is an area of intense focus for the health care industry, the private sector has
not converged on a standardized care coordination model. This makes care
coordination an opportunity for VA to be a leader in developing innovative solutions with
strategic partners within the high-performing network.
For all Veterans, care coordination will fall along a continuum of intensity, from basic
care coordination or patient navigation to care/disease management to case
management, as illustrated in Figure 2. This continuum is influenced by a variety of
factors: the complexity of clinical conditions, Veterans preference around engagement,
PCP choice, and care setting. VA currently offers many diverse care coordination
programs that can be difficult to understand and navigate. VA plans to consolidate these
9
http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html (accessed
September 22, 2015)
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10
Independent Assessment Report H. Health Information Technology. VA should explicitly identify mobile
applications as a strategic enabler to increase Veteran access and satisfaction and help VHA transition to a datadriven health system.
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Care/Disease Management
Care management is the oversight and management of a comprehensive care plan for
a population of patients with specific diseases. Care management facilitates the
delivery of clinically recommended care to optimize health outcomes for Veterans and
avoid gaps or duplications in care. Veterans in need of care management will be
identified through clinical information and PCP referrals. This program will allow VA to
proactively conduct Veterans outreach, encourage healthy behavior, advance clinical
best practices, provide disease education, and engage Veterans in self-management.
As a result, VA will be in a position to better address care needs earlier and support
positive long-term outcomes.
Case Management
Case management is a specialized and highly skilled component of care coordination.
Case management emphasizes a collaborative process that assesses, advocates,
plans, implements, coordinates, monitors, and evaluates health care options and
services, so they meet the unique needs of the complex patient. Case management is
the most intensive level of care coordination. A multidisciplinary team manages care for
Veterans with the most catastrophic and complex conditions (e.g., TBI and spinal injury)
and coordinates treatments across multiple providers and venues of care. Dedicated
case managers use a holistic approach to coordinate and manage Veteran health care,
including consideration of psychosocial factors that affect care. Innovation in this area
can include novel methods for the integration of housing assistance with substance
abuse and mental health care for homeless Veterans.
Veterans who require case management often have a family member or caregiver who
assists them with a variety of personal care activities, ranging from assistance in
arranging and coordinating care, to assistance with Activities of Daily Living (ADL)
and/or Instrumental ADL, or keeping them safe in the community. Support of family
members and friends who serve as caregivers is essential in order for Veterans to
achieve their treatment goals. Caregiver training and support programs also will be
available to family members and caregivers of Veterans who are being treated for
complex conditions, allowing Veterans to obtain the comprehensive, integrated support
they need.
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information transactions and care teams will use the platform to support Veterans in
their health care experience. Through team management, aspects of patient
navigation, care management, and case management can address short-term issues or
issues over extended periods of time.
In addition to individual Veterans and their care teams, information and coordination can
also support population management. Population management is a data-driven
process for proactively defining a cohort of patients who might benefit from a health
care plan or intervention aimed at primary or secondary prevention. This allows care
teams to offer the right service to the right Veteran at the right time.
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3.4
The MyVA Transformation Plan will modernize VAs culture, processes, and capabilities
in order to put the needs, expectations, and interests of Veterans first. It will improve
the Veteran experience by empowering employees to deliver excellent customer
service, improving or eliminating processes that
MyVA Priorities
impede customer service, and rethinking how to
become more Veteran centric. 11 The five
Improving
the Employee Experience to
priorities of MyVA align directly with the
Better Serve Veterans
components of the New VCP.
Improvement
Improving the Veteran Experience. VA exists
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care and improve the experience of Veterans. This culture is key to a system of
systems approach and will require VA to simplify processes and reduce waste. Data
analytics are required for this type of improvement, such as identification of the highest
performing community providers or outreach to Veterans who would benefit from higher
intensity care coordination. Continuous improvement aligns VA with health plan best
practices and will be necessary for ongoing PPA compliance.
Enhancing Strategic Partnerships. Enhancing strategic partnerships will allow VA to
provide higher-quality care to Veterans and better manage costs. VA will continue to
strengthen relationships with: DoD, IHS, THP, FQHC, and academic teaching affiliates.
VA will also identify and engage high-quality community providers in an external
network to provide Veterans with the best possible health care. Finally, VA will work
with CMS and Accountable Care Organizations (ACOs) to evolve toward value-based
care models. This will support VAs high-performing network.
3.5
The design of the future VA health care delivery system, including the New VCP, is
intended to advance Veterans well-being and support their caregivers, community
providers, and VA, as a whole, through improvements in clinical care, business
processes, and customer service.
Impact to Veterans. Veterans should have access to the best care anywhere through
a high-performing network that preserves a Veterans choice in choosing community
providers. Access to emergency treatment will be expanded and Urgent Care needs
will be addressed. VA will actively engage Veterans, their families, and caregivers in
their health care choices, providing innovative tools to help Veterans stay healthy and
manage chronic conditions, as well as connect with their care team in person or
virtually. Enhanced care coordination will improve Veterans health outcomes and
improve health care services received by Veterans. The consolidated community care
program will have clear eligibility criteria, streamline referral and authorization
processes, make customer support available when needed, and eliminate ambiguity
around eligibility and personal financial obligations for care. While providing clarity,
eligibility criteria will also be flexible enough to respond to unique needs of Veterans,
such as excessive burden in travelling to a VA facility or the clinical need to be seen by
a provider in a timeline that is shorter than the VA wait-time standard for a particular
service. Veteran eligibility for community care will be evaluated over time depending on
health care innovations and changes to the Veteran population, such as the increasing
number of women Veterans.
Impact to Community Providers. With the enhancements of the New VCP,
community providers will want to work with VA. A single, efficient referral process will
reduce confusion in care transitions and expedite the process of getting Veterans the
care they need. Increasing health IT adoption and interoperability standards will provide
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3.6
Achieving the enhancements discussed above and arriving at the future state of VA
health care will not happen overnight. Without the necessary resources, authorities,
and legislation, the New VCP will not succeed. The transformative changes set forth in
this plan will require an investment of time and resources to enable Veterans to
effectively access community care. VA will need the ability to evaluate its physical
footprint to support appropriate resource allocation. In addition, funding and budgetary
relief is requested to supplement the capital investment required to build and enhance
existing systems; details are included in the cost and budget portion of this report
(Section 5). VA also requires the necessary authorities to consolidate its programs and
design the system of systems that will be the future of VA health care delivery. Specific
legislative proposal recommendations are included in this report (Section 6). VA will
work closely with members of Congress and their staff on legislation to establish the
New VCP and welcomes discussion on how these changes will affect Veterans.
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4.0
4.1
Legislation
A standardized method to furnish such care and services that incorporates the
strengths of the non-Department provider programs into a single streamlined program
that the Secretary administers uniformly in each Veterans Integrated Service Network
(VISN) and throughout the medical system of the VHA.
Summary
Key Activities
VA considered the larger VA health care system and the environment of health care as
a whole when consolidating community care programs. The New VCP will have a
single set of eligibility criteria for Veterans seeking community care. This program will
also improve the Veteran experience by providing a level of care coordination that
meets the needs of the individual Veteran. It will establish a high-performing provider
network, structured with tiers that will allow VA to preserve existing relationships with
Federally funded partners and academic teaching affiliates, while increasing access to
high-quality community providers. It will also implement a consistent approach for
accessing care (referrals and authorizations), sharing medical information, and
processing provider payment (claims). Over time, existing mechanisms for purchasing
care will either be folded into the New VCP or phased out.
To support a consistent and positive Veteran experience, VA plans to implement a
streamlined system of systems approach for the New VCP that will be integrated with
the VAs internal health care system. The component systems for the New VCP are:
1) Integrated Customer Service Systems, 2) Integrated Care Coordination Systems,
3) Integrated Administrative Systems (Eligibility, Patient Referral, Authorizations, Billing,
and Reimbursement), 4) High-Performing Network Systems, and 5) Integrated
Operations Systems (Enterprise Governance, Analytics, and Reporting).
12
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This program represents a significant organizational change for VA. It will require
detailed planning, system and process redesign, and implementation, as well as action
by Congress. Accordingly, VA has developed a transition plan that will be implemented
over three phases (see Legislative Element 10Transition Plan). This phased
approach will allow VA to make necessary changes to meet the care needs of Veterans
in the short term, while simultaneously designing and implementing an integrated
system that supports the long-term vision for VA health care.
Programs, such as the Civilian Health and Medical Program of the VA (CHAMPVA),
Camp Lejeune Family Member Program, Spina Bifida Health Care Benefits Program,
Children of Women Vietnam Veterans (CWVV) Health Care Program, and the Foreign
Medical Program (FMP), will continue to exist as they do today because their eligible
populations do not typically receive care at VA facilities and foreign care requires a
specialized set of administrative processes. VA will, however, use standardized
systems established for the New VCP to promote operational efficiency for all
community care programs.
Background
Representative Community Care
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Current State
VA has a number of statutory authorities, programs, and other methods for purchasing
community care, as outlined in the Descriptions of Each Non-Department Provider
Program and Authority section of this report. As mentioned above, the various methods
for receiving community care have conflicting structures, responsibilities, ownership,
and management, with different application at the local and national levels. This leads
to inconsistencies in their use and implementation across facilities, from Veteran to
Veteran, and from one episode of care to another. Ultimately, the multiple methods and
overlapping roles, responsibilities, and processes lead to inefficient execution and
significant confusion among Veterans, community providers, VA providers, and staff. In
addition, many of these methods have differing requirements and processes for key
components, including, but not limited to, eligibility criteria and eligibility determinations;
referrals and authorizations; provider credentialing and network development; care
coordination (including medical records management); reimbursable out-of-pocket
expenses (e.g., urgent/emergent outpatient prescriptions); and claims management.
This challenge is exacerbated by the inconsistent level of customer service available to
Veterans and community providers, creating difficulties in resolving inquiries, appeals,
and grievances. Finally, it is difficult to evaluate which programs are operating well
because performance data is not consistently collected.
Future State
The New VCP plans to consolidate existing methods for community care into a single,
efficient program integrated into the broader context of VAs health care system.
A Veteran-centric design will provide straightforward eligibility criteria and a single set of
clinical and administrative systems and processes, allowing Veterans choice in
providers and effective care coordination. This addresses the Independent Assessment
Report recommendation that VA and Congress should eliminate inconsistencies in
current authorities and provide VA with more flexibility to implement a purchased care
strategy. 13 The New VCP will honor VAs special relationships with strategic partners,
such as DoD, IHS, THP, FQHC, and academic teaching affiliates.
The Program also will involve the design and implementation of the five component
systems that will integrate into the system of systems for the New VCP. The
component systems of the New VCP are 1) Integrated Customer Service Systems,
2) Integrated Care Coordination Systems, 3) Integrated Administrative Systems
(Eligibility, Patient Referral, Authorization, and Billing and Reimbursement),
4) High-Performing Network Systems, and 5) Integrated Operations Systems
(Enterprise Governance, Analytics, and Reporting. This section provides a high-level
description of the consolidation of existing methods for purchasing community care as
well as each of the component systems and processes for the New VCP. Additional
details on many aspects of the program are contained later in this report.
13
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14
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providers they wish to see (see Legislative Element 2Patient Eligibility Requirements).
The New VCP also establishes a single streamlined process for referrals and care
authorizations and will define a select list of services requiring prior authorization (see
Legislative Element 3Authorization Process). The Program will implement a claims
solution to accurately and efficiently adjudicate all claims for community care, based on
a simplified reimbursement rates and value-based payments (see Legislative Element
4Billing and Reimbursement Process, Legislative Element 5Provider
Reimbursement Rate, and Legislative Element 7Prompt Payment Compliance). The
New VCP also will provide more convenient access to pharmacy services and DME
while preserving VAs favorable, volume-driven rates for these services. It will also
include partnering with a retail pharmacy network to support convenient access for
urgent/emergent fill prescriptions. The revised processes will preserve VAs
volume-driven buying power while providing these services in a more intuitive and
convenient way for Veterans and community providers.
15
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In order to provide VA and Congressional leadership with visibility into the performance
of the New VCP, VA will implement a consistent reporting process across facilities,
using best practices for metrics, data collection, and reporting. Wherever possible,
metrics will be consistent with industry and other Federal agencies to allow VA to
benchmark quality of care and program performance against peer organizations.
Metrics will include outcomes related to Veterans access to care, utilization of care, the
quality and value of care, and Veteran and community provider satisfaction with the
program. Metrics will provide VA with the information necessary to improve care and
health outcomes for individuals (e.g., using claims and medical records data to identify
conditions requiring disease management), which will show the Programs impact on
Veterans. This aspect of the New VCP also responds to the recommendation that VA
should collect better data to accurately estimate the demand for and use of purchased
care from the Independent Assessment Report. 16
Risks and Implementation Considerations: Refer to the Transition Plan (Legislative
Element 10) section of this report.
Impact
Table 1: Impact of the Single Program for Non-Department Care Delivery
Stakeholder
Potential Impact
Veteran
The New VCP creates an efficient, intuitive, and Veteran-centric experience for community
care through streamlined eligibility criteria and administrative and clinical processes. There
will be less confusion for Veterans as to when and how they can access community care.
Community
Provider
The New VCP will simplify and standardize community providers interaction with VA.
Streamlined processes for referrals and authorizations, exchange of medical records and
care coordination, and claims submission and reimbursement consistent with best practices
should increase providers willingness to participate in the VA network.
VA
Consolidating existing community care programs into the New VCP will reduce confusion
among VA providers and staff about when and how to use community care. It should also
greatly improve VAs community care operations, allowing VA to focus on providing excellent
care and service to Veterans.
16
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4.2
Legislation
An identification of the eligibility requirements for any such care and services, including
with respect to service-connected [(SC)] disabilities and non-SC disabilities.
Summary
Currently, overlapping eligibility criteria for different
Key Activities
methods of accessing community care creates
Create a single, consistent set of
confusion among Veterans, community providers,
eligibility requirements
and VA staff. Eligibility to enroll in and access VAs
Expand and simplify access to
health care system will not change with the New
emergency treatment and urgent care
VCP. However, the New VCP defines a single set
of eligibility requirements for the circumstances
under which Veterans may choose to receive health benefits from community providers.
This will enable timely and convenient access to care in alignment with best practices.
Background
Current eligibility creates confusion due to multiple, overlapping criteria for each
different method of purchasing care. The New VCP will reduce confusion by
standardizing requirements across facilities regarding when a Veteran may choose to
receive community care, while still providing local flexibility to respond to unique needs
of Veterans (e.g., local services, geography, and undue burden). The need for
simplifying eligibility criteria directly addresses the recommendation to Streamline
programs for providing access to purchased care and use them strategically to
maximize access. outlined in the Independent Assessment Report 17 The eligibility
criteria will be grouped into the following categories:
Hospital Care and Medical Services: Patient eligibility criteria for the New VCP will
provide Veterans with timely and convenient access to care based on wait-times,
distance to a VA PCP, or availability of services.
Emergency Treatment and Urgent Care: Eligibility criteria will increase access to
these services and simplify access rules to prevent the denial of claims for the
appropriate use of these services.
Outpatient medication and DME; extended care services: Eligibility criteria will
not be altered in this report, as any adjustment would constitute a fundamental
change to the VA health benefit.
VA compared the current eligibility criteria for purchasing community care to commercial
health plans and Federal program approaches to develop the New VCP criteria. A
number of findings from this review informed design of the patient eligibility criteria for
the New VCP.
17
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18
19
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Current State
VA has multiple sets of eligibility criteria for the various authorities and methods of
purchasing community care. Several of these criteria overlap, creating confusion
among Veterans, community providers, and VA staff and providers. Broadly, these
criteria have focused on providing surge capacity and have been grouped into three
categories:
1. Wait-Times for Care: VA was not able to provide the service within an acceptable
time frame, based on medical need.
2. Geographic Access/Distance: A VA facility was not available within an acceptable
travel distance of the Veterans home.
3. Availability of Service: A facility in the local VA network either did not provide the
required service or there was a compelling reason why the Veteran needed to
receive care from a community provider.
Additionally, eligibility varies by the category of care (hospital care and medical
services; emergency treatment; extended care; outpatient medication; and DME):
Specific Criteria
Wait-Times for
Care
Veterans Choice
Program
PC3
Individual authorizations
Federally funded
partnerships
Academic teaching
affiliates
Geographic
Access/
Distance
The Veteran lives >40 miles driving distance from the closest
VA facility with a full-time primary care physician
OR
The Veteran faces an excessive burden in accessing a VA
facility, including:
Geographical challenges
Environmental factors
Medical conditions that affect travel
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Veterans Choice
Program
Eligibility
Category
Specific Criteria
Availability of
Service
PC3
Individual authorizations
Project ARCH
PC3
Individual authorizations
Federally funded
partnerships
Academic teaching
affiliates
Dialysis Contracts
Emergency Treatment
Currently, a Veteran is eligible to receive emergency treatment through community care
by authority of 38 U.S.C. Section 1703, 38 U.S.C. Section 1725, and 38 U.S.C.
Section 1728. Eligibility for emergency treatment varies by authority. Table 3 outlines
the current-state eligibility criteria for emergency treatment.
Table 3: Current-State Eligibility CriteriaEmergency Treatment
Authority
Specific Criteria
38 U.S.C. Section
1728
It is determined that the care needed met the definition of emergency treatment under 38
U.S.C. Section 1725(f)(1)
AND
The Veteran was receiving care for an SC condition or a non-SC condition is held to be
aggravating an SC condition, or the Veteran is permanently and totally disabled, or in certain
instances when the Veteran is participating in a vocational rehabilitation program under 38
U.S.C. Chapter 31
AND
The claim is filed within two years of the date of service
38 U.S.C. Section
1725
It is determined that the care needed met the definition of emergency treatment under 38
U.S.C. Section 1725(f)(1)
AND
The emergency services were provided in a hospital emergency department or similar facility
held out as a providing emergency care to the public
AND
The Veteran is enrolled for VA health care
AND
The Veteran has received care from VA in the 24 months prior to the receipt of the
emergency care
AND
The Veteran is personally liable for the payment for the care
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Authority
Specific Criteria
AND
The Veteran is not eligible for reimbursement under 38 U.S.C. Section 1728
AND
The claim was filed within 90 days of the date of service
38 U.S.C. Section
1703
Note: Prudent Layperson Definition of Emergency. When such care or services are
rendered in a medical emergency of such nature that a prudent layperson reasonably
expects that delay in seeking immediate medical attention would be hazardous to life or
health. 20
Since determination of these claims is nuanced, and unclear for Veterans, there are a
large number of denied claims. When denied, the financial responsibility for these
claims, which can be substantial, often falls on Veterans or their OHI, resulting in
unanticipated financial challenges for Veterans. As an example, between the beginning
of FY 2014 and August 2015, approximately:
89,000 claims were denied because they did not meet the timely filing requirement.
140,000 claims were denied because a VA facility was determined to have been
available.
320,000 claims were denied because the Veteran was determined to have OHI that
should have paid for the care.
98,000 claims were denied because the condition was determined not to be an
emergency. 21
In FY 2014, approximately 30 percent of the 2.9M emergency treatment claims filed with
VA were denied, amounting to $2.6B in billed charges that reverted to Veterans and
their OHI. Many of these denials are the result of inconsistent application of the
prudent layperson standard from claim to claim and confusion among Veterans about
when they are eligible to receive emergency treatment through community care.
Additionally, VA is not authorized to reimburse Veterans for urgent care, which is
typically lower cost than emergency treatment, and encourages health care in the
appropriate setting.
Extended Care
VA provides extended care through community providers via a number of different
mechanisms. It is out of the scope of this effort to adjust the eligibility criteria for
20
21
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extended care, as any change would constitute a fundamental change to the VA health
benefits package.
Future State
The New VCP does not make changes to the VA health benefit or eligibility
requirements for enrollment in VA health care. The Program will give Veterans who are
eligible for community care the choice to access some or all of their health benefits in
the community, when the medically needed care is not conveniently available in a VA
facility.
The objective of the New VCP is to create a set of criteria that are simple and intuitive
for Veterans, community providers, and VA staff. This will be accomplished by
eliminating the multiple overlapping criteria for accessing Hospital Care and Medical
Services, including Dentistry, in the community. The single, nationally defined set of
eligibility criteria for the New VCP can be consistently implemented while providing VA
facilities the flexibility to respond to unique circumstances, such as excessive burden in
traveling to a VA facility or the medically-indicated need to see a provider in a timeline
shorter than the VA wait-time standard for a service. In addition, the New VCP includes
simple criteria for accessing Emergency Treatment and Urgent Care. This should
increase access and reduce denied claims while incentivizing appropriate use of these
services.
Eligibility criteria for each category of care are described below.
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When Veterans are determined to be eligible for community care, VA will provide them
with information on providers and appointment availability at VA and in the community.
This will allow Veterans to choose a convenient appointment from the provider of their
choice. The proposed eligibility criteria for Hospital Care and Medical Services are
outlined in Table 4.
Table 4: Future-State Eligibility CriteriaHospital Care and Medical Services
Eligibility
Criteria
Proposed Criteria
Veterans Choice Program Future State
Wait-Times for
Care
An appointment cannot be scheduled within VA wait-time goals for providing the service or
within the clinically necessary time frame indicated by the provider if that time frame is less
than VA wait-time goals
Geographic
Access/Distance
The Veteran lives 40 miles or farther driving distance from a PCP as designated by VA
OR
The Veteran faces excessive burden in accessing care at a VA facility, including:
Geographical challenges
Environmental factors
Other factors (nature of care, frequency of care, and need for an attendant)
Availability of
Service
A facility does not provide the service or has chosen to buy service from the community
OR
There is a compelling reason why the Veteran needs to receive the service outside a VA
facility (e.g., female victims of MST unable to be seen by a female provider)
The primary change in this proposal is to focus eligibility for geographic access/distance
on access to a PCP. PCPs play a critical role in coordinating care and providing
preventative care, so convenient access is necessary. Veterans eligible for the New
VCP under either of the geographic access/distance criteria will have the option to
choose a community PCP. The community PCP could then refer the Veteran to
specialty care in the community or at VA as appropriate and authorized by VA. This
approach is consistent with best practices, which emphasize providing access to a PCP.
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Proposed Criteria
Veterans Choice Program (Future State)
Emergency
Treatment
1.
2.
3.
4.
Urgent Care
Extended Care
No changes are being made to how VA provides extended care in the community. The
majority of these services are provided in the community today and changing the
eligibility criteria would constitute a fundamental change to the VA health benefit.
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Impact
Table 6: Impact of the Patient Eligibility Requirements
Stakeholder
Potential Impact
Veteran
The New VCP eligibility criteria will reduce confusion among Veterans about when they
are eligible to receive community care and for what services they are eligible. It also
will expand access to community care for emergency treatment and urgent care
services and limit cases where Veterans are held responsible for a bill for emergency
treatment or urgent care because they did not fully understand the criteria for VA
coverage. In addition, the New VCP will provide Veterans with increased choice in
providers they can see in the community.
Community Provider
Community providers will have a clearer understanding of what services the Veterans
they see are eligible to receive under the New VCP.
VA
The New VCP eligibility criteria will provide VA providers and staff with clear,
consistent guidance on when Veterans should be referred to the community. They
also will reduce confusion about which method to select for purchasing care for a
particular Veteran or service and reduce the administrative burden on VA of
individually reviewing all emergency treatment claims.
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4.3
Element 3: Authorizations
Legislation
A description of the authorization process for such care or medical services, including
with respect to identifying the roles of clinicians, schedulers, any third-party
administrators (TPAs), the VAs Chief Business Office, and any other entity involved in
the authorization process.
Summary
Currently, VAs process for referrals and
Key Activities
authorizations to coordinate care, manage clinical
Redesign clinical authorization process
utilization, and improve health outcomes is largely
Create centralized authorization
manual. This causes delays in care and
function
Reduce number of services requiring
inconsistency in reviews. Best practices call for
authorization
automation and process improvement for
Create and collect metrics to monitor
authorization reviews. VA will use a system of
effectiveness of new authorization
systems approach to establish and refine business
process
rules, create a central authorization center, train
staff, and implement technologies to support referrals and authorizations. VA will
standardize the approach to referrals and authorizations. The business rules and
process will be consistent for internal and community provided services. VA intends to
benchmark and monitor performance, addressing the Independent Assessment
recommendation to align performance measures to those used by industry, giving VA
leadership meaningful comparisons of performance to the private sector. 22
Background
Referrals and authorizations are mechanisms to coordinate and manage community
care while managing medical need and cost, as defined in Table 7
Table 7: Referral and Authorization Definitions
Definition
Key Word
Referral
Authorization
PCPs play a pivotal role in coordinating care. Referrals enable a Veteran to receive
services through another provider. However, certain services, such as purely cosmetic
procedures not related to remediation of an underlying health condition, high-cost
services, or experimental services, require additional clinical review to confirm necessity
22
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and consistency with best practices. Referral and authorization processes should be
standardized inside and outside VA, and facilitated through automation to enable more
proactive Veteran care management. To support effective implementation, the provider
network should be routinely educated. To manage disputes, a formal appeals process
will be implemented.
Current State
Currently, the referral and authorization process varies by program and whether a
Veteran is accessing care due to wait-times or geographic access/distance criteria. All
non-emergent services require a referral and administrative documentation. This
process is repetitive, time consuming, and lacks clear ownership. Furthermore, a new
referral or authorization may need to be generated for services covered within the same
episode of care. The current process is variable across VA sites and is carried out by a
variety of individuals with multiple roles and varying skill levels. There are no clear
performance metrics to evaluate the efficiency of the process. Consequently, there is
no clear ownership of the process, making it challenging to track and improve.
Future State
The New VCP will improve the referral process through automation and removal of
redundant reviews. A subset of services will require an authorization for the care to be
provided based on medical necessity to improve visibility into utilization of these
services. For consistency, authorizations will be managed centrally and supported with
industry accepted standards and clinical guidelines. This will facilitate the development
of performance metrics to continuously evaluate and improve the authorization process,
and support improvement in utilization of services for best value for the Veteran.
A call center will be available for questions from Veterans, caregivers, and community
providers. A formal, timely appeals process will provide Veterans a clear point of
contact for concerns about the status of their authorization.
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Impact
Table 8: Impact of Authorizations
Stakeholder
Potential Impact
Veteran
Veterans will have timely access to care and a clear understanding of when and where
they are eligible for care. When authorization questions arise, there is a clear path for
appeals through the call center. Veterans will receive care that is effective and
consistent with clinical guidelines and industry practices.
Community Provider
Community providers will benefit from authorization requirements consistent with industry
standards and experience a decrease in administrative burden. This will provide more of
an incentive to participate in the high-performing network.
VA
VA will benefit from a decreased administrative burden and have a standard process with
defined accountability, consistent outcomes, and reduced turnaround times. Central
authorization control will enhance VAs visibility into Veterans needs. The central
authorization process will improve staff competency and efficiency.
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4.4
Legislation
The structuring of the billing and reimbursement process, including the use of thirdparty medical claims adjudicators or technology that supports automatic adjudication.
Summary
Key Activities
The current billing and reimbursement system
Introduce automation, including auto
is a decentralized and highly manual process.
adjudication, to billing and
A successful billing and reimbursement system
reimbursement processes
auto adjudicates a high percentage of claims to
Create and collect metrics to monitor
pay providers promptly and correctly. To
effectiveness of billing and
reimbursement processes
achieve this, best practices dictate using
centralized services and technology, combined
with standardized processes and business rules. This addresses the Independent
Assessment Report recommendation to employ industry standard automated solutions
to bill claims for VA medical care (revenue) and pay claims for Non-VA Care (payment)
to increase collections, to improve payment timeliness and accuracy. 23 To achieve
these improvements, VA will implement new business processes and conduct analyses
to determine potential claims solutions.
Background
Efficient adjudication is the key to effective billing and reimbursement processes.
High-performing networks invest in centralized, scalable auto adjudication technology
platforms and use simplified product and reimbursement rules to facilitate high levels of
auto adjudication. This enables automation of most claims and only requires review of
claims in question, reducing delays in payment. While this type of technology
investment will have significant up-front costs, efficiency gains, savings, and additional
key analytic capabilities will be generated once the solution is complete.
Auto adjudication of claims is made possible by establishing standard rules and
processes, and integrating with complete patient and provider data. Systems
interoperability allow for flexibility, enabling organizations to quickly respond to
regulatory and best practice changes. Modern claims platforms can model care
outcomes, and identify fraud, waste, and abuse through data analytics. Industry
standards do not require the receipt of medical records for payment. VA does have this
requirement, which often causes delays in payment. As VA improves claims
processing, VA will no longer require medical records for reimbursement. VA will strive
to improve the automation of systems to process medical records and conduct
23
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retrospective audits to confirm their receipt and develop lessons learned to support
continuous improvement.
Current State
The current VA claims infrastructure and claims process are complex and inefficient due
to highly manual procedures, and VA lacks a centralized data repository to support auto
adjudication.
There are more than 70 centers processing claims across 30 different claims systems,
resulting in inconsistent processes. Limited automation and manual matching of claims
to authorizations prevents efficient adjudication. Low electronic data interchange (EDI)
claims submission rates, decentralized and inconsistent intake processes, and limited
staff productivity standards (i.e., workload metrics) result in labor-intensive, paper-based
processes that generate late, and sometimes incorrect payments.
Future State
VA will pursue a claims solution and simplified processes as it evolves to achieve parity
with best practices. VA will focus on:
In the long term, VA will use a scalable, flexible claims platform that supports emerging
value-based care models, and streamlines data maintenance, storage, and retrieval.
This new claims solution will support VAs efforts to reduce waste, fraud, and abuse. In
addition, the VA claims solution will integrate with Veteran Eligibility Systems,
Authorization Systems, and standardized fee schedules to support auto adjudication.
Integration with fee schedules will support new payment models and enable better
tracking and billing integration with OHI (See Legislative Element 5Provider
Reimbursement Rate). VA will also integrate the claims processing system with patient
information, increasing VAs ability to efficiently bill OHI. As VA becomes more efficient
with processing claims, it will consider consolidating claims processing for other
programs (e.g., CHAMPVA). Taken together, the new claims solution will allow VA to
pay on time and correctly while meeting PPA compliance (see Legislative Element 7Prompt Payment Compliance). VA will coordinate referral management with tracking
financial obligations to provide the basis for resource and process adjustments based
on forecasted versus actual use of funds.
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VA will determine whether to improve the system through the adoption of a new system
or by purchasing the required capabilities externally. VA will oversee adherence to
business rules, standardize internal controls, and have proper access to systems
holding information to be reviewed. Keeping in line with best practices, VA will conduct
claims audits for accuracy. VA also will provide compliance oversight for the New VCP
Prompt Payment compliance process owner in accordance with VA Directives,
Handbooks, and other applicable policies. To monitor and improve performance of
billing and reimbursement, VA will use industry standards as metrics for continuous
process improvement.
Risk and Implementation Considerations: For additional information, refer to the
Transition Plan (Element 10) section of this report.
Impact
Table 9: Impact of Billing and Reimbursement
Stakeholder
Veteran
Potential Impact
Implementing new claims systems will reduce the risk of billing Veterans when provider
reimbursement is either delayed or denied.
Communications improvements in customer care will directly improve the Veteran
experience. Systems integration and auto adjudication will improve the efficiency and
accuracy of claims from community providers, and thereby introduce more clarity around
timing of billing and reduce the risk of Veterans referred to collections notices by
community providers.
Timely re-imbursement of community providers will motivate such providers to participate
in the VA provider network, thereby improving access for Veterans.
Community Provider
Improved processes, rules, and systems will improve claims processing accuracy and
predictability, enable VA to comply with the PPA, and therefore provide an incentive for
providers to join and remain in the network.
VA
By improving VAs billing and reimbursement policies and processes, VA will improve
timeliness, accuracy, and efficiency of claims processes, reducing costs associated with
late penalties, and strengthen business analytics and utilization review capabilities of the
Department.
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4.5
Legislation
A description of the reimbursement rate to be paid to health care providers under such
program.
Summary
Key Activities
Currently, VA establishes provider rates through
Consolidate fee schedules and tie to
local negotiations using a complex, inconsistent
Medicare
process. This results in a lack of transparency for
Increase transparency of
community providers and VA staff regarding
reimbursement rates to providers
reimbursement rates. High-performing networks
Allow regional variation, as needed
provide transparency to providers through
standardized, negotiated reimbursement rates. VA will standardize reimbursement
rates to align with regional Medicare rates under a single program and will remain the
primary payer. For services not covered by Medicare, VA will use other fee schedules
or conduct negotiations around usual and customary (U&C) rates. U&C rates are rates
paid for a medical service in a geographic area based on the amount providers in the
area usually charge for the same or similar medical service. This is consistent with the
Independent Assessment Report recommendation VA and Congress should adopt a
consistent strategy for setting reimbursement rates across purchased care initiatives. 24
VA will continue to use established payment mechanisms with DoD, IHS, THP, FQHC,
and academic teaching affiliates while at the same time moving toward paying Medicare
rates for commercial partners. The change will allow VA staff to more easily match
rates and reduce variance in the rates being paid to community providers. As the health
care industry evolves, VA will participate in models of value-based care to provide the
highest quality care for Veterans.
Background
The purpose of a fee schedule is to communicate the rate a provider will be paid for the
services they render. The design of the fee schedule may incentivize providers to
participate in the network and can be used to reward delivery of high-quality care.
CMS is the largest primary payer in the U.S. and employs a Medicare rate-setting
committee that influences market reimbursement rates. The CMS fee schedule
includes geographic variations for care along with Graduate Medical Education, among
other factors. For services not specified in the fee schedule, organizations will pay U&C
or negotiated rates.
To create incentives for better health outcomes, best practices are shifting from a feefor-service model to value-based care arrangements. In this model, organizations
24
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Current State
Through legislation and VA-implemented programs, a number of community care
programs overlap in the services they provide and have multiple fee schedules. The
schedules are set both locally and nationally, which increases variation and complexity
across programs and medical centers. Finally, in some instances, VA pays billed
charges for services without a corresponding rate in a schedule in lieu of negotiating a
more favorable rate.
The current state is confusing for VA staff and community providers. Staff performing
this function are challenged to accurately identify the appropriate reimbursement rate,
causing lengthy processing times and overpayment. Community providers are unsure
about what rate they will be paid when seeing Veterans
Future State
VA will standardize, to the extent practicable, to Medicare rates for the external network.
VA proposes a single rate schedule for the New VCP to provide a clear basis for claims
payment, which will promote timely payments and prevent overpayments through
negotiated rates when a Medicare rate does not exist. This will end the existing
structure of providers having multiple schedules per service. Dentistry 25 will be
reimbursed differently as the Office of Dentistry will continue to use the market to
determine and apply regional market rates for their services. VA will continue using
existing agreements with partners in the VA Core Network; pending legislation will allow
VA to direct care to these authorities (see Legislative Element 6 Provider Eligibility).
VA also plans to evolve toward a value-based care model as the concept matures. As a
facet of value-based care, Preferred providers will be incentivized with higher
reimbursement rates when they meet or exceed performance metrics. Providers may
receive higher reimbursements based on their performance against quality metrics. In
contrast, providers who consistently perform below expected levels may be dropped
from the network. Further, VA will employ an audit function to verify quality in the valuebased model.
Due to their geographic and/or market cost distinctions, VA will customize fee schedules
for certain areas (e.g., Alaska, Hawaii, Guam, Puerto Rico, American Samoa, and the
Commonwealth of the Northern Marianna Islands) or certain services (e.g., scarce
25
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specialties and dental care) to maintain a sufficiently robust provider network in these
regions.
Risks and Implementation Considerations: For additional information, refer to the
Transition Plan (Legislative Element 10).
Impact
Table 10: Impact of Provider Reimbursement Rate
Stakeholder
Potential Impact
Veteran
Veterans will benefit from increased provider participation and choice in options since
providers are reimbursed at predictable industry rates. Veterans also will have access to
high-performing providers. This will lead to greater access to providers in the community.
Community Provider
Community providers will benefit from consistent reimbursement rates. Standardized fee
schedules will decrease provider confusion and reduce payment errors. Since rates will
be based on a common schedule with which they are already familiar, there will be little
surprise for providers who see increases or decreases in their rates per service.
As value-based reimbursement is implemented, providers will be rewarded for providing
higher-quality care.
VA
For VA, consistent reimbursement rates will allow for better cost prediction.
Reimbursement rates under the New VCP will reduce payment errors due to elimination
of manual selection of various fee schedules by examiners. Consistent payment rates
will enable better data analytics to support fraud detection
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4.6
Legislation
An identification of how the Secretary will determine the eligibility requirements of
health care providers at non-Department facilities to participate in such program,
including how the Secretary plans to structure a non-Department care network to allow
the maximum amount of flexibility in providing care and services under the program.
Summary
Key Activities
Background
To identify provider eligibility requirements and design the high-performing network for
VA, this element examines best practices for provider networks, credentialing, and
quality standards.
26
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R. Steinbrook, The Cost of AdmissionTiered Copayments for Hospital Use, New England Journal
of Medicine; 2004
32 J. Burns, Narrow Networks Found to Yield Substantial Savings, Managed Care; 2012
Page 55
In the U.S., health care is not delivered consistently. There are notable differences in
health care spending, resource utilization, and quality of care depending on factors such
as the licensed health care professional, medical facility, geographic region, and patient
population. Increased utilization and spending do not always lead to better outcomes. 33
To promote consistent high-quality care that is safe, timely, effective, efficient, and
patient centered, industry-leading organizations are working to measure provider
performance and recognize high performers. Metrics employ evidence-based
performance criteria based on rigorous and transparent methodologies. Sources for
quality measures can include NCQA, the National Quality Forum, AHRQ, and The Joint
Commission. Effective coordination of care and health information management also
directly affect quality of care (see Introduction: Care Coordination and Legislative
Element 9Medical Records Management).
Current State
Current VA community provider relationships are formed through multiple overlapping
programs with Federally funded health care assets and commercial providers. VA
contracts or has agreements with approximately 40 DoD facilities (with access to
TRICARE Managed Care Contractors on a case-by-case basis), 100 IHS facilities, 80
THPs, 700 academic teaching affiliates, 700 FQHCs, 76,000 locally contracted
providers, and 200,000 additional providers through current national contracts. Despite
the large numbers of providers, VA does not have ongoing visibility into many provider
locations, nor an understanding of supply and demand imbalances. Therefore, VA does
not have coverage in certain areas to provide accessible care to Veterans, nor a single
mechanism to actively manage provider relationships.
VA has multiple processes for credentialing community providers and different
credentialing criteria, depending on the authority that is the basis for furnishing
community care.
VA does not have a standardized approach to measure delivery of quality care in
contracts and agreements with community providers. Some sharing agreements are
administered locally, and quality reporting requirements vary depending on the
agreement. As a result, VA currently has limited visibility into best-in-class providers.
Once providers have joined the network, VA does not have a national mechanism to
track quality of care issues. With variable quality monitoring processes, providers are
held to different standards and VA faces a larger burden in monitoring quality
compliance.
33
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Future State
To align with VAs mission to better serve Veterans, VA plans to provide access to a
high-performing network drawing from best practices across industry and Federally
funded organizations (See Table 11).
Table 11: Key Elements of the High-Performing Network
High-Performing Network
VAs high-performing network will be divided into the VA Core Network and the External
Network (Figure 5). The External Network is subdivided into Standard and Preferred
tiers. VA will work toward standardizing requirements with providers in the highperforming network.
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The VA Core Network will include providers in the DoD, 34 IHS, THPs, 35 FQHCs, and
academic teaching affiliates. 36 VAs relationships with these providers are unique and
have evolved over time. Sustaining and expanding Core Network relationships align
with VAs mission, vision, and strategies (see Legislative Element 8: Plans to Use
Current Non-Department Provider Networks and Infrastructure). Because Core
Network providers will be considered a direct extension of VA care, VA will primarily
refer patients to the Core Network before the External Network. 37 VA will work to
develop simple and consistent agreements with Core providers that are principle-based
and focus quality and outcomes.
External providers can belong to Standard or Preferred tiers, which will expand over
time. VA plans to make the process for joining the External Network simple. Providers
in the Standard and Preferred tier must meet uniform credentialing requirements to
participate in the high-performing network. Providers in the Preferred tier must meet
minimum credentialing requirements while also demonstrating high-value care.
The high-performing network will require network development, contracting and
reimbursement, credentialing, clinical quality monitoring, and provider relations
functions. VA will employ an audit function to oversee credentialing and adherence to
quality standards.
Veterans will have the ability to choose community providers and make informed
decisions based on public information. Veterans currently accessing community care
can remain with their community providers, if the provider meets minimum
requirements, or choose other providers in the network. Veterans also can recommend
their providers for addition to the network. VA will consider publishing provider
designations, credentials, and Veteran feedback. To promote awareness about military
culture and unique issues Veterans face, VA will encourage providers to complete
relevant trainings and make available educational resources.
VA faces significant access challenges in delivering care to Veterans due to geographic
limitations and the unique needs of the Veteran population. VA plans to include the
34
The inclusion of Managed Care Contractors through TRICARE will be evaluated separately during
implementation phases.
35 Refers to all Tribal Health Programs that meet CMS certification and CMS conditions of participation, or
have accreditation through the Accreditation Association for Ambulatory Health Care or The Joint
Commission, with which VA has entered a Direct Care Services Reimbursement Agreement.
36 Academic teaching affiliates refers to academic departments or program that have active teaching
relationships with VA and can be part of the VA Core Network. Other academic institutions or
departments without teaching relationships can be part of the External Network. VA plans to retain or
expand relationships under VA Directive 1663.
37 In general, VA plans to refer patients to Core Network providers first, with exception. For example, VA
does not generally refer patients to IHS and THP providers under Direct Care Services Reimbursement
Agreements, and does not plan on changing this arrangement.
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highest quality providers, but also recognizes the need to establish a broad and flexible
network providing convenient care near to where Veterans live.
In the high-performing network, credentialing processes will be simple, consistent, and
in alignment with best practices (see Table 12). The re-credentialing process will
evaluate ongoing provider qualifications to confirm health outcomes and adherence to
standards. These can include value, complaint history, Veteran experience, and a
baseline assessment of care appropriateness every 24-36 months. VA will audit and
enforce credentialing practices in the high-performing network.
Table 12: High-Level Provider Credentialing Standards
Provider Credentialing Standards
VA will work directly with providers currently caring for Veterans to include them in the
network for continuity of care. Providers who meet credentialing criteria will complete a
simple enrollment process and can join the VA network. Over time, poor performing
providers will be removed from the network.
In the VA Core Network, VA will delegate credentialing or perform credentialing
functions when applicable. Federally funded credentialing institutions can include DoD,
IHS, and the HRSA for FQHCs. VA will evaluate current credentialing practices to
determine whether there are difficulties and identify ownership of the process. In the
External Network, either VA or a network manager will assume ownership of
credentialing and will apply industry-leading practices.
VA will work toward establishing simple, consistent, and high-quality agreements with
Core and External Providers in the high-performing network. In order to promote quality
of care, VA will monitor and enforce rigorous quality reporting and performance
standards in line with industry, conduct data analytics on disease management, and
share VA critical pathway information. VA plans to shift toward adopting value-based
care models in the high-performing network (see Legislative Element 5- Provider
Reimbursement Rate).
Creating a prioritized Core Network will maximize the use of high-quality Federally
funded health care assets, while sustaining unique and important VA relationships. In
the External Network, VA promotes high-quality care by creating Preferred and
Standard tiers. For the Preferred designation, providers must meet quality and value
metrics that are based on evidence-based care guidelines. VA plans to uniformly apply
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best practices to determine criteria for both tiers. VA will work to determine specific
metric reporting and performance benchmarks using recognized institutions.
Risks and Implementation Considerations: Refer to the Transition Plan (Legislative
Element 10) section of this report.
Impact
Table 13: Impact of Provider Eligibility
Stakeholder
Potential Impact
Veterans
Veterans will have increased access to high-quality care through an expanded network
that promotes quality. Veterans can remain with their existing community providers, if
providers meet minimum requirements, or choose other providers who are best in
class to support their health care needs.
Community Providers
Providers in all tiers will benefit from simpler, consolidated, and integrated claims
processing, medical records management, and provider support services through VA.
Providers in the VA Core Network and Preferred tier may see an increase in patient
referral volume in addition to benefits realized in the Standard tier.
VA
VA will have increased visibility into supply and demand in the network, centrally
monitor provider credentialing and quality, and promote high-value care.
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4.7
Legislation
An explanation of the processes to be used to ensure that the Secretary will fully
comply with all requirements of Chapter 39 of the Title 31, United States Code
(commonly referred to as the PPA), in paying for such care and services furnished at
non-Department facilities.
Summary
Key Activities
Background
In 1982, Congress enacted PPA, which requires Federal agencies to pay vendors on a
timely basis and pay interest on late payments. While PPA regulation requires payment
to be made within 30 days after an invoice is received, it does not specifically reference
health-related claims nor define clean claims. A clean claim is one that has all
information required for processing in a timely manner; it has no defect, impropriety, or
special circumstance. An unclean claim is one that is missing information. State
governments have enacted different Prompt Payment legislation that requires health
plans to adhere to certain time frames for claims processing. As a reference, the
average state standard is 30 days for clean claims (ranging from 14-45 business
days).22 This requirement will be clarified in the legislative proposal recommendations.
Current State
Currently, VA does not consistently meet PPA standards. In some programs, such as
CHAMPVA, a 30-day claim processing rate of 95 percent is achieved. However, as of
September 30, 2014, VA paid 76.7 percent of claims within 30 days. A root cause of
low PPA compliance is that claims payment is a manual process, creating a significant
backlog (See Legislative Element 4Billing and Reimbursement). To address the
backlog, VA developed and is executing a phased action plan in terms of people,
process, and technology.
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Future State
In the short-term, VA plans to reduce the current backlog by increasing the number of
claims staff. It aims to adhere to best practice guidelines used by several states (e.g.,
paying within 30 days for clean claims). 38 In the long term, VA will use industry best
practices to reach a 95 percent payment rate for clean claims within 30 days. To
achieve this, VA will consider alternate solutions, such as outsourcing billing and
reimbursement, or deploying new technology solutions or updates.
VA will have a mechanism for the reporting and monitoring of claims processing to
manage inventory to PPA standards. VA will establish internal controls that would allow
regular review and updates to the process to obtain additional information about how to
process claims promptly. VA will also review, update, and retrain staff on policies and
procedures to comply with PPA. This will include training both internal staff and TPAs
on new claims adjudication procedures. VA will establish an audit function to monitor
claims processing accuracy. Efforts to develop a consolidated program and automated
claims processing system will allow VA to consistently meet PPA.
Risk and Implementation Considerations: For additional information, refer to the
Transition Plan (Legislative Element 10) section of this report.
Impact
Table 14: Impact of Prompt Payment Compliance
Stakeholder
Potential Impact
Veterans
Community Providers
VA
38
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4.8
Element 8: Plans to Use Current Non-Department Provider
Networks and Infrastructure
Legislative Overview
A description of how, to the greatest extent practicable, the Secretary plans to use
infrastructure and networks of non-Department provider programs that exist as of the
date of the plan to implement such program.
Summary
Key Activities
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Future State
VA intends to build a high-performing network using successful components of its
current infrastructure to meet Veterans needs (see Legislative Element 6Provider
Eligibility). 42 VA plans to retain and potentially expand agreements with the Core
Network, composed of existing Federally funded partners (DoD, IHS, THPs, 43 and
FQHCs) and academic teaching affiliates. 44 Core Network providers will be treated as a
direct extension of VA care. VA will refer patients to the Core Network before referring
them out to the External Network. 45 VA will work to develop simple and consistent
agreements with Core providers driven by quality and health outcomes.
VAs relationships with Core Network providers are unique and have evolved over time.
Sustaining and expanding Core Network relationships aligns with VAs mission, vision,
and strategies. VAs Core Network maximizes collaboration with Federal health
organizations and supports their missions. 46 DoD resource sharing agreements support
the nations defense readiness mission. Relationships with academic teaching affiliates
align with VAs education and research missions. High-quality providers in IHS, THPs,
and FQHCs promote access to exceptional care for Veterans where they live, including
rural and medically underserved communities. 47 FQHCs require rigorous quality and
risk management policies and approximately 70 percent of FQHCs have earned Patient
Centered Medical Home recognition or accreditation by the NCQA. 48
Remaining community partners meeting minimum credentialing criteria will be able to
join VAs high-performing network. They can participate in the Preferred or Standard
tiers of the External Network. The Standard tier requires only the minimum
credentialing criteria. To join the Preferred tier, these providers must also meet quality
criteria and demonstrate high-value care. VA will work to include community providers
currently serving Veterans to maintain continuity of care. Veterans can recommend
42 Other programs, such as the Camp Lejeune Family Member Program, CHAMPVA, and the Foreign
Medical Program will continue to exist separately from the New VCP
43 Refers to all Tribal Health Programs that meet CMS certification and CMS conditions of participation, or
have accreditation through the Accreditation Association for Ambulatory Health Care or The Joint
Commission, with which VA has entered a Direct Care Services Reimbursement Agreement.
44 Academic teaching affiliates have active teaching relationships with VA and are part of the VA Core
Network. Other academic institutions without teaching relationships are part of the External Network. VA
plans to retain or expand relationships under VA Directive 1663.
45 VA plans to refer patients to Core Network providers first, with exception to IHS and THPs. VA does
not currently refer patients to these institutions and does not plan on changing this arrangement.
46 VA 2014-2020 Strategic Plan
47 VA.govVA Mission and Vision Statements
48 Uniform Data System, 2014Bureau of Primary Health Care/Health Resources and Services
Administration
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existing providers for inclusion in the network and VA will work to create a simplified
provider enrollment process.
Risks and Implementation Considerations: Refer to the Transition Plan (Legislative
Element 10) section of this report.
Impact
Table 15: Impact of Network and Infrastructure
Stakeholder
Potential Impact
Veterans
VA will make it simple for eligible Veterans to choose community providers through an
inclusive network arrangement that maintains relationships with existing high-quality
health care assets. In addition, network changes will increase Veteran choice and
access to high-quality providers.
Community Providers
Core Network partners will have enhanced relationships with VA to serve Veterans.
Community providers will have a simple process for joining the External Network.
VA
VA will retain and potentially expand unique and high-priority relationships with Core
Network providers. VA will have increased visibility into supply and demand in the
network, centrally monitor provider credentialing and quality, and promote high-value
care.
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4.9
Legislation
A description of how(A) health care providers at non-Department facilities that furnish
such care or services to Veterans under such program will have access to, and transmit
back to the Department, the medical records of such Veterans and (B) the Department
will receive from such non-Department providers such medical records and any other
relevant information.
Summary
Current VA health information exchange
practices are primarily paper-based, with manual
handoffs and inconsistent processes that create
delays. Access to current health information is
critical to supporting care coordination and
delivery of high-quality care. In the future, VA will
develop a health information environment that is
electronic, secure, efficient, effective, Veteran
centered, and standards based. 49,50,51
Key Activities
Improve consistency, simplicity, and
timeliness of information exchange
Deploy provider viewers and health
information gateway
Increase use of Health Information
Exchanges
Background
Medical records management, referred to as health information management in this
element, is the practice of acquiring, analyzing, transferring, and protecting digital and
traditional medical information vital to providing quality patient care. 52 Health
information can be divided into two categories: clinical and administrative. Clinical
information includes patient medical histories, physical findings, test results, treatments,
and clinical practice guidelines that document appropriate treatments for conditions.
Administrative information supports the business functions of health organizations and
can include medical claims, formularies, and patient referral documents. Health
systems that effectively manage health information are able to seamlessly send,
receive, locate, and access reliable and relevant information.
49
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53 Office of the National Coordinator for Health Information Technology (ONC HIT) http://www.healthit.gov/providers-professionals/health-information-exchange/what-hie
54 United States Department of Health and Human Services, Health Resources and Services
Administration (HRSA) definition
http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Collaboration/whatishie.html
55 The Sequoia Projecthttp://sequoiaproject.org/wp-content/uploads/2014/11/eHealth-ExchangeOverview-7-23-15.pdf
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Current State
VAs current process for management of health information internally and in the
community needs to simplify and improve consistency and timeliness (Table 16). In the
current state, after an appointment is scheduled, information enters the Veterans Health
Information Systems and Technology Architecture (VistA), which provides an electronic
health record (EHR) for enrolled Veterans and administrative tools. The process is
different if the Veteran is seen by a provider in the contractor networks, authorized on
an individual basis, or treated by a Federal provider in DoD or IHS.
Table 16: Current-State Limitations for Health Information Management
Current-State Limitations
For care through contractor networks, VA manually sends clinical and administrative
information through hard copies or fax to be uploaded to a contractor portal or
document repository. The applicable contractor provider then downloads appropriate
clinical and administrative information from the portal in preparation for the appointment.
For care through individual authorizations, VA sends information directly to providers via
print, fax, or sometimes electronic methods.
After the visit, contractors upload health information to the contractor portal and send
paper-based versions of clinical and administrative information back to VA. VA
administrative staff then manually scan and import the paper documents into VistA.
Individually authorized providers can either use the same manual practices or use VA
exchange services to transfer information back to VistA. VA exchange services
electronically exchange clinical information with community providers, including identity,
authorization and consent, and data translation functions.
After information reaches VistA from community providers (including DoD and IHS), VA
providers can then log into the Computerized Patient Record System (CPRS) or
VistAWeb applications, which allow providers to enter, review, and update Veterans
clinical information. VA staff with appropriate security credentials can view
administrative information through VistA Imaging.
VA is working on several initiatives to promote interoperability with DoD and IHS
providers, including sharing viewable data in existing (legacy) systems, developing a
virtual lifetime EHR, implementing IT capabilities for the first joint Federal health care
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center, 56 and direct secure messaging pilots. Plans also are in place to develop and
pilot tools to optimize VAs infrastructure, and VA has released mobile applications to
give Veterans and providers on-demand access to health information.
Future State
VA will adopt a phased plan consistent with a systems approach to achieve a solution
that is secure, efficient, effective, and standards based, using HIEs. Future state
systems will facilitate data transparency to promote enterprise-wide data collection,
analytics, 57 and prioritize data security. In the near-term, VA will focus on building upon
current infrastructure to improve consistency, simplicity, and timeliness of information
exchange. In the medium-term and long-term, VA plans to deploy a robust health
information gateway and services, the Enterprise Health Management Platform (eHMP),
and share most clinical information through HIEs.
Near-Term Improvements
In the near term, VA is implementing a web-based Joint Legacy Viewer (JLV) to offer a
simple, complete, and easy to understand view of VA and DoD patient data. Secondly,
VA plans to integrate existing exchange services to receive and store standards-based
electronic documents, such as Continuity of Care Documents. This reduces use of
paper and builds on current VA investments. Thirdly, VA plans to expand partnerships
with HIEs and use direct secure email protocols. Lastly, for health IT, built or bought,
VA plans to expand the usage of national standards for clinical terminology and data
elements. Community providers not using JLV or the HIEs will continue to receive
requisite health information through current state infrastructure (Table 17).
Table 17: Near-Term Improvements for Health Information Management
Near-Term Improvements
Electronic Health Records: VA and DOD Need to Support Cost and Schedule Claims, Develop
Interoperability Plans, and Improve Collaboration. GAO. Accessed September 30, 2015.
http://www.gao.gov/products/GAO-14-302.
57 Independent Assessment Report (Care AuthoritiesSection 5), Improve collection of data on Veteran
health care utilization and reliance
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implement a health information gateway and associated services, the eHMP, and share
most clinical information through HIEs, when available.
Table 18: Medium & Long Term Improvements for Health Information Management
Medium- and Long-Term Improvements for Health Information Management
Implementation of the Health Information Gateway and Services and the eHMP
Most clinical information shared through HIEs, increasing health information interoperability and availability
Increased support for care coordination and clearer definitions of information ownership
Support for data-driven audit and evaluation 58
User-friendly tools involving minimized use of paper-based information
Additional mechanisms to promote data privacy and security
Providers will be able to view, append, and share clinical and administrative information
electronically through a VA health information gateway and associated services
(Figure 6). Veteran clinical and administrative information will then be transferred back
to VistA. VistA will incorporate an industry-leading information model, terminology
normalization, knowledge enrichment, and search indexing for VA, Federal, and HIE
partner sources. Available health information will drive enterprise-wide analytics efforts
for process improvement.
Specifically, the health information gateway and services will include integrated point-ofcare applications for Veterans, community providers, and staff. Services refer to
technologies that facilitate privacy and security, data translation, and data storage. VA
will create a data-driven evaluation process for provider adherence to VA critical
pathways to promote high-quality and high-value care.
VA will deploy the eHMP in the medium-term, which will replace CPRS and include JLV
capabilities. eHMP will integrate end-user clinical encounter and care coordination
transaction capabilities, data visualization, and decision support services. eHMP will
feature a common electronic care plan with standardized protocols tailored to individual
Veteran needs. Information gathered through patient-facing and telehealth technologies
will update the care plan (see Care Coordination for additional detail).
VA will share most clinical information through HIEs and work with ONC, national
standards organizations, and industry associations to move toward full standardization
of health IT components. VA will use national standards for data elements such as
labs, medications, allergies, and vitals. Data interoperability standards will promote
seamless handoffs of more complete patient records between VA and community
providers.
58
Expanded data and reporting documentation to include Affordable Care Act data collection standards:
http://aspe.hhs.gov/basic-report/hhs-implementation-guidance-data-collection-standards-race-ethnicitysex-primary-language-and-disability-status will be included to meet VHA Strategic Goal 1E
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Impact
Table 19: Impact of Medical Records Management Requirements
Stakeholder
Potential Impact
Veterans
Veterans will benefit from better care coordination due to the ease of clinical and
administrative information flow between VA and community providers.
Community Providers
Community providers will benefit from quick, user-friendly processes for accessing
and submitting clinical and administrative information. Improving the community
provider experience could incentivize additional providers to join VAs network.
Timely access to clinical information can lead to more informed decisions to improve
quality of care.
VA
VA providers will also benefit from ease of access to clinical information on their
patients. Improved access to clinical data can lead to improved care coordination
and clinical decision-making. VA will benefit from automating practices and using
common standards, legal agreements, and governance, which can reduce
administrative costs and promote higher-quality care delivery for Veterans. Applying
analytics to health information can show public health patterns, effective disease
management, and ways to use resources more effectively.
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Background
The New VCP is a key component of how VA will deliver care in the future. Currently,
VA has multiple disconnected systems and processes to perform clinical and
administrative functions for purchasing care. This is inefficient and causes confusion
among Veterans, community providers, and VA staff. Under the New VCP, these
disparate systems and processes will be consolidated and streamlined into an
integrated system for a seamless experience for all stakeholders. In addition, as this
plan is reviewed and updated to incorporate input from Congress and other
stakeholders, the activities and resources required to consolidate community care
programs will likely be impacted.
The New VCP will be implemented through a system of systems approach. As outlined
in the Introduction to this report, a system of systems approach involves the design,
deployment, and integration of meta-systems that are themselves composed of complex
systems, which are integrated to deliver the desired functionality and end-to-end user
experience. 59 Consistent with this approach, VA will begin by understanding the
desired experience and required outcomes for Veterans, caregivers, VA staff, and
community providers. VA will then examine all the components necessary to achieve
the desired outcomes and understand how various component systems will integrate
into the broader VA health care system and funding environment. To successfully
implement this system of systems approach requires legislative changes, resources and
budget. Requested changes are outlined in the Estimated Costs and Budgetary
Requirements (Section 5) and Legislative Proposal Recommendations (Section 6) of
this plan. If legislative changes are not provided within the requested timelines, it will
adversely affect VAs ability to deliver the New VCP as described in this plan.
Implementation of the system of systems approach will be executed through rapid cycle
deployment using agile methodologies. This will allow VA to fix the most pressing
issues with community care today, while making continuous updates to promote a
learning health system that evolves with the needs of the Veteran population. This
approach enables VA to implement an integrated system design that allows people,
59
Adapted from: Lia, P., Fisk, R. P., Falco e Cunha, J., & Constantine, L. (2011). Multilevel service
design: From customer value constellation to service experience blueprinting. Journal of Service
Research, 14(2), 180200.
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Functional Area(s)
Customer Service
Care Coordination
High-Performing Network
Change Management
Program Management/Enterprise Governance
Data Collection, Analytics, and Reporting
In order to execute a program of this scope and scale, VA has outlined a transition plan
consistent with the system of systems approach to sequence the design, development,
and delivery of the New VCP. In developing the transition plan, VA considered
recommendations from stakeholder feedback and the Independent Assessment Report.
While the transition plan lays out a path forward for the program, the complexity of the
change will require development of detailed implementation plans. In addition, any
changes to the New VCP described in this plan as a result of input from Congress or
other stakeholders will impact the activities described.
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changes implemented in Phase I through interfaced systems that will appear seamless
to Veterans and community providers, but will largely continue to employ existing
infrastructure and technology. Phase III will be a multi-year effort. For the purpose of
this report, only the first year of Phase III has been outlined. In Phase III, VA will begin
deploying an integrated system of systems that will support changes in Phases I and II
and enable a seamless experience across VA and community care for all stakeholders.
VA also will collect and analyze data on the progress and performance of the
implementation to identify opportunities for continuous improvement. Overall, through
all phases of the transition, VA will build a foundation for a health care system that can
respond to the evolving needs of Veterans and the changing health care landscape at
VA and in the community. Figure 7 outlines representative requirements for each
component system in each phase, illustrating how each phase will build on the previous.
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Key Requirements:
Customer Service Solutions: VA will use customer service solutions aligned
with MyVA to provide prompt, responsive customer service for the New VCP.
Over time, this will include the definition of robust, outcome-focused customer
service metrics that will inform regular evaluation and improvements to the
process.
Key Requirements:
Consolidate care management system: Design a consolidated care
management system to standardize care coordination activities, analyze
additional care and disease management needs, and evaluate the quality of
care provided.
Communicate a consistent care coordination model: Conduct a care
coordination assessment to develop care coordination policies and
procedures. Enhance existing pilot programs to improve Veteran health
outcomes and models and begin piloting case management/disease-specific
programs. Integrate programs with the health information gateway for
community providers.
Improve information sharing: Design a system to facilitate the sharing of
medical records between providers using standards and terminology to
support interoperability. Continue to expand medical records access and
clinical information sharing via HIEs.
Apply analytics to identify target populations for care programs: Use
data to identify Veterans for disease/case management programs. Conduct
outreach to VA staff, community providers, and eligible Veterans to increase
awareness.
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Key Requirements:
Eligibility:
Define eligibility for the New VCP: Define and communicate eligibility
to promote convenient access for Veterans, and reduce confusion
among Veterans, community providers, and VA staff. This will include
communication to key stakeholders regarding the impact of the New
VCP and revised eligibility requirements.
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Key Requirements:
Develop a high-performing network: Identify core competencies and
gaps in current networks and develop a high-performing network with the
features described in this report. Continue to conduct analyses to identify
network gaps and define utilization standards that are consistent for
network and VA for providers. Establish necessary systems to support a
high-performing network and develop communications for stakeholders.
Standardize provider eligibility criteria: Develop policies and
procedures to improve operational efficiency, including standardizing fee
schedules, delegating credentialing, contracting, and continuously
evaluating processes and policies for further improvements. Support
identification of high-performing network providers using data analytics
and uniform standards.
Adopt quality and value-based payment methodologies: Support
value-based payments for community providers using emerging models
from industry.
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Key Requirements:
Establish Governance and Management for the New VCP: Establish
local and national management for community care. Standardize
management structures for community care within facilities and establish a
new DUSH for Community Care to support a consistent Veteran
experience with the New VCP. Develop a schedule, milestones, and
budgets to support implementation of the New VCP and promote
integration with the VA health care delivery system. Develop
comprehensive communication and training materials for all stakeholders
on changes to VA systems, policies, and procedures.
Analytics and Reporting: Support decision making by improving
information and transparency to optimize health outcomes, analytics, and
program management. Evaluate options for a consolidated reporting
solution for the New VCP to aggregate and standardize data and conduct
necessary analysis.
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requested timeline, VA will not be able to fully execute the New VCP. For additional
information regarding requested legislative authorities, please refer to the Legislative
Proposal Recommendations section of this report.
Funding: To support the New VCP, VA will need to deploy the integrated system of
systems described above. This deployment also will require a significant change
management effort, including communications and training. To implement this
transformation, VA will need additional funding. If funding for the changes proposed
in this report is not provided, it will affect VAs ability to deliver the New VCP as
described in this report. For additional information regarding requested funding,
please refer to the Estimated Cost and Budgetary Requirements section of this
report.
Timelines: The estimated times for completion of phases described in this transition
plan are aggressive and intended to position VA to implement streamlined
processes and meet the care needs of Veterans quickly. If legislative and budgetary
requests are not approved, or the New VCP does not receive appropriate support
from internal and external stakeholders, these timelines may be adversely affected.
Culture Change: The New VCP is a major change for VA and will require Veterans,
VA staff, and community providers to embrace community care as an integral
element of the VA health care system. If the program implementation or change
management efforts are not well planned or managed, stakeholders may not buy in
to the change, adversely affecting the programs chances of success.
Stakeholder Input and Buy-In: The New VCP described in this plan is notional and
represents VAs perspective on the path forward for VA Community Care. Congress
and other stakeholders will have input into the final design of the program. If input
from stakeholders requires modifications to the New VCP as described in this plan,
the transition plan and associated timelines may need to be updated to account for
these changes.
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Risks
Mitigation Strategies
Element 4: Billing
and
Reimbursement
Process
Element 5:
Provider
Element 2:
Patient Eligibility
Requirements
Element 3:
Authorization
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Legislative
Element
Risks
Mitigation Strategies
Reimbursement
Rate
Element 6: Plan
to Develop
Provider Eligibility
Requirements
Element 8: Plans
to Use Current
Non-Department
Provider
Networks and
Infrastructure
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Legislative
Element
Risks
Mitigation Strategies
with different models at the state level that does not
impact the Veteran experience from site to site
Element 7:
Prompt Payment
Compliance
Develop and implement training for claimsprocessing staff. Develop clear strategy to reduce
the claims backlog. Create incentives to increase
electronic submission of claims
Element 9:
Medical Records
Management
Element 10:
Transition Plan
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Legislative
Element
Risks
Mitigation Strategies
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5.0
Legislative language
Estimated costs and budgetary requirements to implement the plan and to furnish
Hospital Care and Medical Services pursuant to such plan.
Introduction
Consolidating purchased care programs is critical for the long-term success of VA as an
integrated care delivery system. Currently, VA has multiple disconnected processes to
perform clinical and administrative functions associated with purchasing care. In
addition, there are multiple legal authorities with different criteria and business rules for
the various purchased care programs. This variation causes confusion among
Veterans, community providers, and VA staff. Under the New VCP, these disparate
authorities, business rules, processes, and systems will be consolidated into a single
program that supports the future vision of VA outlined in this plan.
A transformation of this scale requires VA to take a system of systems approach,
examining all the components of the system and optimizing desired outcomes, rather
than trying to optimize component parts. This approach must take a holistic view of
Veteran care and consider changes that affect care both inside the VA and in the
community. Using this approach, VA has identified required changes to five clinical and
administrative systems: Integrated Customer Service Systems, Integrated Care
Coordination Systems, Integrated Administrative Systems (Eligibility, Patient Referral,
Authorization, Billing, and Reimbursement), High-Performing Network Systems, and
Integrated Operations Systems (Enterprise Governance, Analytics, and Reporting).
Delivering the New VCP will not be successful without approval of requested legislative
changes and required budget. Discussion of the estimated budget increase associated
with implementing this plan is divided below into three sections: (1) System Redesign
and Solutions; (2) Hospital Care and Medical Services, including Dentistry; and (3)
Expanded Access to Emergency Treatment and Urgent Care. System Redesign and
Solutions include enhancements to the referral and authorization process, care
coordination and customer service, and claims processing and payment. These
changes are expected to improve the Veteran experience with community care. This
may result in an increase Veteran reliance on VA community care, leading to the
increased health care costs described in the Hospital Care and Medical Services
section. Expanded Access to Emergency Treatment and Urgent Care is important in
providing Veterans with appropriate access to these services, but is severable from
other aspects of the program and could be implemented separately. This section
details the estimated budget increase associated with the each area described above,
as well as the methodologies and assumptions used in generating the estimates. Note
that the cost estimates in this section represent incremental increases above VAs
Page 87
existing Community Care program, which includes historical costs of hospital care,
medical services, and long-term services and supports (approximately $7 billion a year
in the base budget), and assumes the continuation of the existing Veterans Choice
Program with no modification (approximately $6.5 billion additional cost annually).
Page 88
Table 22: Estimated Incremental Costs for New VCP System Redesign & Solutions
Phase I
Incremental
($ M)
$ 421
Phase II
Incremental
($ M)
$ 606
Key considerations for the System Redesign and Solutions cost drivers are outlined
below:
Incremental Cost of New VCP Hospital Care and Medical Services Eligibility
The Hospital Care and Medical Services, including Dentistry, eligibility criteria for the
New VCP do not represent a significant change from the eligibility criteria outlined in
The Choice Act and the VA Choice and Budget Improvement Act. For example, the
New VCP preserves access to community care based on wait-time and geographic
access/distance criteria, the more detailed excessive burden guidance, and recent
removal of the requirement of enrollment prior to August 2014. Despite minimal
changes in eligibility criteria, an increase in Veteran reliance on VA community care is
expected as System Redesign and Solutions described above meaningfully improve the
Veteran experience with community care. The estimates in Table 23 below document
Page 89
the expected incremental costs, which are primarily associated with (1) an increased
reliance on VA for those eligible under the Geographic Distance/Convenience criteria,
(2) a shift to Medicare Fees Schedules, and (3) Revenue Offsets.
Table 23: Estimated Incremental Costs for New VCP Hospital Care and Medical
Services Eligibility Changes
Phase I
Incremental
($ M)
Phase II
Incremental
($ M)
2,064
2,318
(205)
(171)
1,859
2,147
Key considerations for Hospital Care and Medical Services Eligibility are outlined below:
Initial Cost Drivers: Health care costs for the New VCP are primarily driven by an
increased reliance on VA for those eligible under the Geographic
Distance/Convenience criteria, a shift to regional Medicare Fees Schedules, and
increased Revenue Offsets from Veteran OHI.
- Geographic Distance/ConvenienceThe New VCP Geographic
Distance/Convenience eligibility criteria offer enrolled Veterans who live more
than 40 miles from a VA PCP access to community care. Because of
enhancements in customer service and care coordination proposed under the
New VCP, a greater demand for community care is anticipated from this
population. VA assumed that the reliance of the enrollee population originally
eligible under The Choice Act (approximately 600,000) will increase to 50 percent
from roughly 37 percent anticipated in 2017. In addition, for all enrollees eligible
under The Choice Act and The Veterans Choice and Budget Improvement Act
(approximately 900,000), approximately half of the care they would have been
expected to receive in VA facilities under their historical level of reliance is
expected to move to the community through the New VCP.
- Medicare Allowable CostsCost estimates for the New VCP assume that VA
will pay regional Medicare rates, plus typical administrative costs for health care
services provided through the program. Because some community care has
traditionally been purchased above these rates, this change will lead to a
decrease in the cost of community care.
- Revenue Offset Increased Veteran utilization of community care as a result of
New VCP System Redesign and Solution Improvements will, in some cases, lead
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to increased collections from Veteran OHI. These collections will offset some of
the health care services costs.
Phase II
Incremental
($ M)
2,045
2,137
(644)
(648)
1,401
1,489
Page 91
may represent options for offsetting health care costs of community care going forward.
VA has not yet developed estimates for the magnitude of these potential savings.
Identifying Services Best Performed in the CommunityAs VAs highperforming network develops, certain services (high quality, high value) may be
identified to be the best or more efficiently provided by the community and not by
VA. Should these services shift to the community, VA may be able to repurpose
associated internal facilities for other uses. The amount of potential savings from
these changes depends on the specific services that are referred into the community
and the timelines to repurpose resources.
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6.0
Legislation
The Secretary shall submit to the Committees on Veterans Affairs of the House of
Representatives and the Senate a report containingany recommendations for
legislative proposals the Secretary determines necessary to implement such plan
Introduction
To successfully implement critical reforms, VA needs additional legislative authorities to
improve access to community care, consolidate VAs community care programs,
improve emergency treatment and urgent care services, and realign current processes
to support reforms. This section provides detailed information regarding the legislative
changes needed to address current deficiencies and improve the health care services
Veterans receive. Without these additional authorities, VA will not be able to implement
the New VCP and make critical reforms.
The primary objectives of the legislative proposal recommendations are to make
immediate improvements to community care, establish the New VCP, and implement
necessary business process improvements. The legislative proposal recommendations
are divided into three sections: Immediate Improvements to the Veterans Choice
Program, Establishing a Single Program for Community Care, and Process and
Organizational Improvements.
1. Immediate Improvements to the Veterans Choice Program. The three legislative
proposal recommendations below are necessary to provide VA with the authorities
to improve access to care while beginning to consolidate community care programs.
These proposals would allow VA to work more easily with community providers and
provide VA the flexibility for community care funding. These legislative authorities
are critical to meet the needs of Veterans today and in the future. The legislative
proposal recommendations include:
Improving VAs Partnerships with Community Providers to Increase Access to
Care (Provider Agreements).
Improving Access to Community Care through Choice Fund Flexibility.
Increasing Accuracy of Funding by Recording Community Care Obligations at
Payment.
2. Establishing a Single Program for Community Care. These legislative proposal
recommendations allow VA to consolidate community care, establish a Community
Care Account, phase out unnecessary authorities and programs for community care,
and improve access to emergency treatment and urgent care. These proposals
include:
Improving Veterans Access to Community Care by Establishing the New VCP.
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6.1
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afforded VA by the VA Budget and Choice Improvement Act and it would facilitate VAs
efforts to consolidate and streamline the Departments non-VA care authorities. It is
critical for VA to have flexibility to use existing Choice Funds to pay for care within the
community.
Title: Increasing Accuracy of Funding by Recording Community Care Obligations
at Payment
The purpose of this proposal for appropriations act authority is to address two
inefficiencies in the obligating of funds that were found during a recent Inspector
General (IG) audit. In reality, current processes requirements in this area are
incompatible with the efficient use of resources provided to VA. During a recent IG
audit, it was determined that for FY 2013, more than $500M in Non-VA Care
deobligations had occurred in the first 18 months after the fiscal year end, foregoing
funds that could have provided more health care for Veterans. Additionally, if the
eventual expenditures exceed the obligation amount, a potential violation of the
Anti-Deficiency Act (ADA) is created, unless sufficient prior-year deobligations from
other sources are available at that time. In FY 2014, five VISNs collectively requested
an additional $110M in two-year funds that would have otherwise been available for
FY 2015 requirements because they had underestimated the obligation amount
required for FY 2014 authorizations.
Under current practice, VHA administratively and clinically approves community care
consults. Administrative approval indicates the patient is eligible for a VHA medical
benefits package and care outside the VA, if required. Clinical approval indicates the
care is medically necessary for the patients health and well-being per non-VA Care
Coordination processes. After establishing administrative and clinical approval, the
medical facilitys non-VA Care Team generates an authorization for care. An
authorization gives a community provider authority to provide health care to the Veteran
patient and provides assurance of payment for those services. The authorization
document binds VA to the language that is included on the authorization.
VAs legal liability to pay for community care occurs when the authorization for care is
generated. In accordance with the Recording Statute, 31 U.S.C. Section 1501 and the
ADA, 31 U.S.C. Section 1341(a)(1), VA records an obligation covering the estimated
amount of the non-VA care. These amounts are highly unpredictable and this
unpredictability has led to significant deobligations after the end of the fiscal year,
resulting in large balances of expired prior-year appropriations in the Medical Services
account. The unpredictable nature of the health care needed also adds significant risk
of ADA violations because of under-estimated obligations.
In compliance with the Recording Statute and to protect against potential violations of
the ADA, VA must record obligations when authorizations are issued. Each
authorization may ultimately be used once, several times, or not at all by the Veteran
Page 95
who receives it, but VA must record an obligation amount at the time the authorization is
issued that is sufficient to cover the ultimate expenditures from that authorization.
Expenditures can lag several months to several years after the care has been
authorized, and amounts frequently vary from the original estimated obligations. If the
Veteran does not use an authorization, there are no resulting expenditures.
The penalty for over-obligation is a prior-year de obligation, foregoing funds provided by
Congress with no other penalty. Conversely, the penalty for under-obligation is a
potential ADA violation, with a published report to the President, Congress and the
Government Accountability Office identifying the responsible officials, potential
detrimental administrative action against those officials, and potential criminal penalties
if the violation is determined to have been knowing and willful. Because of the
difference in possible penalties, there is a strong incentive to over-obligate to preclude a
potential ADA violation.
This proposed appropriations act legislation would allow VA to record the obligation
when the amount is certain (i.e., when VA approves the payment of the claim for the
incident of care) without regard to the requirements of the Recording Statute and ADA.
It would likely reduce the potential for large deobligation amounts after the funds have
expired. VA already records obligations for CHAMPVA and Millennium Bill emergency
treatment claims, for which authorizations are not generated, upon payment of the
claim.
This proposed legislation will greatly reduce, and probably eliminate, any potential for
ADA violations, as well as the potential for large deobligation amounts after the funds
have expired. VA already uses this process for CHAMPVA and Millennium Bill
emergency treatment claims, which require no authorizations, without incident. Per
discussion with the DoD Health Affairs TRICARE staff, who have similar authority to that
proposed for VA, there have been no ADA violations resulting from this authority.
6.2
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Veterans Community Care, Medical Services, and Medical Support and Compliance
accounts and the authority to deposit Medical Care Collection Funds receipts into the
Community Care Account.
Title: Streamlining Community Care Funding
This legislative proposal would increase both accountability and visibility on community
care resources and expenditures at local facilities and at higher levels by amending
Section 106(b) of PL 113-146. This provision actually has had the effect of impeding
VA from putting in place an efficient process for funding community care. Under these
requirements, there is no direct link between the resources and the purchased care
demand at the local VA Medical Center level.
We propose Section 106(b) be amended to adapt the current model used for funding
VAs Consolidated Mail-Out Pharmacies (CMOPs), where VA Medical Centers estimate
their total requirement for the year, provide the funds to their supporting CMOP, and
adjust funding levels up or down for variances in demand during the year. Variances
may occur for reasons unknown at the time the budget is submitted, such as the
retirement of a specialty physician that causes demand for purchased care to increase
until a replacement is hired. Conversely, funds that were intended for purchased care
at the beginning of a fiscal year could be realigned to pay for staff at the local VA
Medical Center if successful hiring of scarce medical providers offers an opportunity to
deliver the required care in-house rather than through purchased care.
Title: Improving Veterans Experience by Consolidating Existing Programs
Consolidating and streamlining community care is a central goal of the plan required by
PL 114-41. To meet this requirement, certain existing authorities and programs will
need to sunset. Some of these authorities are described below:
If the New VCP outlined above were enacted, 38 U.S.C. Section 1703, which authorizes
VA to contract for Hospital Care and Medical Services for certain Veterans, would be
superfluous. Section 1703 should be amended to add a sunset or expiration date of
December 31, 2017.
The authority to contract for scarce medical resources, 38 U.S.C. Section 7409, is no
longer utilized. VA currently relies on 38 U.S.C. Section 8153 to contract for these
medical resources. Section 7409 should be repealed.
Project ARCH, Section 403 of PL 110-387 (as amended), was designed to improve
access for eligible Veterans by connecting them to health care services closer to home.
The New VCP will address these same access issues. Project ARCH will sunset in
August 2016 and VA will develop a plan to address continuity of care for affected
Veterans.
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The Assisted Living for Veterans with TBI (AL-TBI) pilot program authorized by
Section 1705 of PL 110-181(as amended) provides assisted living services to certain
eligible Veterans with TBI. The pilot program is currently scheduled to sunset in
October 2017. VA does not provide assisted living services to any other group of
Veterans. This pilot program should not be extended if a true consolidation of
community care is to take place. This pilot of assisted living services is inconsistent
with the scope of the medical benefits that VA provides in all other health programs. As
required by statute, VA is providing quarterly reports to Congress on, among other
things, VAs interim findings and conclusions with respect to the success of the pilot
program. VAs future reports to Congress on the pilot program will make
recommendations for the future direction of care for the Veteran cohort eligible for this
pilot program.
Title: Improving Veterans Access to Emergency Treatment and Urgent Care
The purpose of this legislative proposal is to address VAs existing authorities to
reimburse the cost of emergency treatment. In addition, this proposal would clarify
reimbursement for emergency transportation services. Veterans often seek emergency
treatment with a misunderstanding of VAs authority to pay for their treatment and are
surprised when VA is unable to cover their bills. The complexities of the current law
also creates confusion for those who administer the program. VAs plan envisions an
expanded authority to reimburse costs associated with emergency treatment for
enrolled Veterans, who are active VA health care participants, in a more consistent and
understandable way.
We propose to amend 38 U.S.C. Section 1725 to authorize VA to reimburse the
reasonable costs of emergency treatment and emergency transportation provided to
eligible Veterans. VA would utilize a definition of emergency treatment similar to the
definition specified in current 38 U.S.C. Section 1725(f). Eligible Veterans would be
those who are enrolled and are active health care participants in VA. An active health
care participant is a Veteran who has sought care from VA within the last 24 months.
VA would be the primary payer for the treatment provided under this section. The
provision would authorize VA to set the maximum amount payable under this provision
and specify that VA payment is payment in full. Consolidating VAs emergency
treatment authorities into a single provision and providing a consistent benefit to all
eligible Veterans also would require 38 U.S.C. Section 1728 to be repealed.
In addition, the proposal would authorize VA to pay the reasonable costs of urgent care
provided to an eligible Veteran through an entity under contract or other agreement with
VA. The term urgent care would be defined by the Secretary in regulation. Eligible
Veterans would be those who are enrolled and are active health care participants in VA.
VA would be the primary payer for urgent care provided under this section.
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6.3
Page 100
care and services to provide their health plan contract information to VA. Specifically,
an applicant or recipient of VA medical care or services would be required to provide
information regarding their health plan coverage to include the name of the health plan
contract(s), the name of the policy holder if coverage is under a health plan contract
other than the name of the applicant or recipient, the plan number, and the plans group
code.
The proposal would further authorize the Secretary to define and take appropriate
action when an individual who fails to provide this information. The Secretary also
would be authorized to reconsider the application for or reinstate the provision of care or
services once the information requested has been provided. To be clear, the proposal
would not be construed as authority to deny medical care and treatment to an individual
in a medical emergency. If a medical emergency exists, VA will not deny emergency
treatment or services should the applicant or recipient fail to provide health plan contract
information.
Title: Formalizing VAs Prompt Payment Standard to Promote Timely Payments to
Providers
The purpose of this legislative proposal is to formalize VAs Prompt Pay standard to be
in alignment with the current industry guidelines established by States. This proposal
would establish a section under Title 38 for the Prompt Payment of all care provided in
the community. The legislative proposal should establish what constitutes a clean
claim that will start the payment clock. Generally, a clean claim is defined by States
as a claim that has all the information a payer needs to either pay or deny the claim. A
non-clean claim is a claim that requires additional information or documentation from
the provider. Moreover, there are States that use different time frames for paper clean
claims (usually 45 days) versus electronic clean claims (usually 30 days). In counting
the days, states vary from working/business days to calendar days for processing of
claims. VAs proposal will use the above as a guide.
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6.4
Description
Impact/Justification
Amends 38 U.S.C.
Section 1745
Authorize VA to use
Veterans Choice Fund to
pay for non-Department
Care
Appropriations act
provision to allow VA to
record obligations for
Community Care on the
date on which payment of
a claim to a provider is
approved without regard
to the recording statute or
ADA requirements
Appropriations act to
provide budget authority
in the new the
Community Care Account
Amends 38 U.S.C.
Section 1725
Page 102
Title/Topic
Description
Impact/Justification
Amends 38 U.S.C.
Section 7332 (b)(2)
Amends Title 38 to
require individuals to
provide health care
insurance information
Amends Title 38
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7.0
Legislation
The Secretary shall submit to the Committees on Veterans Affairs of the House of
Representatives and the Senate a report containing a description of each
non-Department provider program and the statutory authority for each such program
Description of each non-Department provider program and statutory authority
As more Veterans seek services through VA facilities, VA has had to increasingly
depend on non-Department providers to meet the evolving needs of Veterans.
Throughout the decades, Congress provided VA with several statutory authorities and
established numerous programs that allow Veterans to seek community care.
Additionally, VA has authority to provide some care and services to certain survivors
and/or dependents. These numerous authorities and non-VA care programs are
cumbersome and oftentimes confusing for Veterans, community providers, and VA staff
to understand and administer.
The five tables below detail VAs authorities to provide community care. These include
VAs contracting authorities (Table 26), reimbursement authorities (Table 27),
community care programs (Table 28), benefits programs (Table 29), and authorities to
contract for specific health care services (Table 30). Each table provides information
regarding the statutory authority, nature of the provision, description, eligibility criteria,
and beneficiary.
Table 26 provides details on three statutes that authorize VA to enter into contracts with
community providers for health care services. Note: Authorities to contract for specific
types of care are detailed in Table 30 below.
Table 26: VAs General Contracting Authorities for Health Care
Title and Statutory
Authorities
Contracts for
Hospital Care and
Medical Services in
Non-Department
facilities
38 U.S.C. Section
1703
Nature of
Provision
Contracting
Description
Eligibility Criteria
Beneficiary
Authority to contract
for Hospital Care
and Medical
Services when VA
facilities are not
capable of
furnishing
economical care
due to geographic
inaccessibility or are
not capable of
furnishing care; can
Criteria specified in
statute and
regulations.
Authority to contract
for care based on
type of care needed
and whether or not
the Veteran is SC.
Certain Veterans as
specified in statute
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Nature of
Provision
Description
Eligibility Criteria
Beneficiary
also furnish
counseling and
related Mental
Health services
under 38 U.S.C.
Section
1712A(e)(1).
Sharing of Health
Care Resources
Sharing authority;
Contracting
Broad authority to
make
arrangements, by
contract or other
forms of agreement,
for the mutual use,
or exchange of use,
of health care
resources between
VA facilities and any
health care
provider, or other
entity or individual.
Sharing agreements
with affiliates are
executed under this
authority.
Veterans or
individuals
authorized to
receive care under
Title 38
Sharing authority
Authority to enter
into sharing
agreements and
contracts with DoD
for the mutual use
or exchange of use
of hospital and
domiciliary facilities,
and such supplies,
equipment, material,
and other resources
as may be needed.
N/A
Veterans Service
members
38 U.S.C. Section
8153
Sharing of VA and
DoD health care
resources
38 U.S.C. Section
8111
Table 27 provides details on the statutes that are cited when VA reimburses community
providers for health care services. These reimbursement authorities are related to
emergency treatment and care provided in IHS/THP facilities.
Page 105
Nature of
Provision
Description
Eligibility Criteria
Reimbursement
Authority to
reimburse the
reasonable value of
emergency
treatment furnished
in a non-VA facility.
Veteran must be an
active health care
participant and
personally liable for
the emergency
treatment (terms are
defined in the law).
Certain Veterans
Reimbursement
Authority to
reimburse the U&C
charges of
emergency
treatment furnished
in a non-VA facility
where such
treatment was
needed for/related
to a SC condition or
in certain instances
vocational rehab (38
U.S.C. Chapter 31),
or provided to a
Veteran
permanently and
totally disabled.
Veteran must be
eligible for VA
health care and
treatment must be
rendered for
conditions specified
in statute.
SC Veterans
Reimbursement
Authorizes the
Secretary of HHS to
enter into or expand
sharing
arrangements
between IHS, tribes,
and Tribal
Organizations, and
VA and DoD. This
authority is cited in
VAs Direct Care
Services
reimbursement
agreements with
IHS and THP.
In general,
agreements apply to
American Indians
and Alaska Native
(AI/AN) Veterans,
eligible for services
from VA and IHS or
the THP. NonAI/AN Veterans may
also be eligible
under agreements
with Alaska THP.
Certain Veterans
38 U.S.C. Section
1725
Reimbursement of
certain medical
expenses
(emergency
treatment)
38 U.S.C. Section
1728
Sharing agreements
with Federal
agencies (IHS/THP
Reimbursement
Agreements)
25 U.S.C. Section
1645
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Beneficiary
Table 28 provides details on the three community care programs that allow Veterans to
access community providers for health care services. 60
Table 28: VAs Community Care Programs
Title and
Statutory
Authorities
Veterans
Choice
Program
Nature of
Provision
Description
Eligibility Criteria
Beneficiary
Contracting
and Provider
Agreement
Certain
Veterans
Pilot
implemented
via contract
Certain
Veterans
based on
driving times
to certain
services
Pilot
implemented
via contract
Certain
Veterans
PL 113-146
Section 101
(as amended)
Project
ARCH
PL 110-387
Section 403
(as amended)
AL-TBI Pilot
Program
PL 110-181,
Section 1705
(as amended)
60
This table does not include VA Dental Insurance Pilot (PL 111-163 510).
Page 107
Table 29 provides details on six benefit programs through which VA provides health care
to eligible Veterans, survivors, dependents, family members, and caregivers through
community providers.
Table 29: VAs Benefit Programs to Provide Services to Veterans, Survivors, and
Dependents
Title and
Statutory
Authorities
FMP
Nature of
Provision
Description
Eligibility Criteria
Benefit
Authority to provide
Hospital Care and
Medical Services
outside a state if such
services are needed for
treatment of a SC
disability or as part of a
rehabilitation plan under
38 U.S.C. Chapter 31.
SC Veterans treated
for SC conditions.
Veterans
Benefit
Certain Survivors,
Dependents, and
Caregivers
Benefit
(Reimbursement)
Provides
reimbursement to family
members of
certain Veterans for
care associated with
specific medical
conditions.
Certain family
members
Benefit
Authority to provide
children of Vietnam
Veterans and Veterans
of covered service in
Korea suffering from
spina bifida with health
care. What constitutes
health care is defined in
statute.
Certain children of
certain Veterans
38 U.S.C.
Section 1724
CHAMPVA
38 U.S.C.
Section 1781
Camp
Lejeune
Family
Member
Beneficiary
38 U.S.C.
Section 1787
Spina Bifida
38 U.S.C.
Section 1803;
38 U.S.C.
Section 1821
Page 108
Title and
Statutory
Authorities
CWVV
Nature of
Provision
Eligibility Criteria
Beneficiary
Benefit
Authority to provide
eligible CWVV with
needed care for that
childs covered birth
defects or any disability
associated with those
birth defects.
N/A
Certain children of
certain Veterans
Benefit
Authority to provide
care to a newborn child
of a woman Veteran
receiving maternity care
from VA for not more
than seven days after
the birth of the child if
the child is delivered in
a VA facility or another
facility pursuant to a
contract.
N/A
Newborn children of
certain Veterans
38 U.S.C.
Section 1813
Care for
Newborn
Children of
Women
Veterans
Receiving
Maternity
Care
Description
38 U.S.C.
Section 1786
Table 30 provides details on 15 statutes that authorize VA to furnish specific care and
services through community providers.
Table 30: VAs Authority to Furnish Specific Services by Community Providers
Title and
Statutory
Authorities
Contract
Nursing Home
Care
Nature of
Provision
Description
Eligibility Criteria
Contract
Contract
Authority to contract or
enter into an agreement
with each State home for
payment of nursing home
care.
Certain SC
Veterans
38 U.S.C.
Section 1720
State Veterans
Homes (Nursing
Home Care)
Page 109
Beneficiary
Title and
Statutory
Authorities
Nature of
Provision
Description
Eligibility Criteria
Beneficiary
38 U.S.C.
Section 1745
Non-institutional
alternatives to
nursing home
care
Contract
N/A
Certain Veterans
Contract
N/A
Veterans
Contract
N/A
Certain Veterans
Contract
N/A
N/A
38 U.S.C.
Section 1720C
Respite Care
38 U.S.C.
Section 1720B
Specialized
Residential Care
and
Rehabilitation
Services to
Eligible
Operation
Enduring
Freedom
(OEF)/Operation
Iraqi Freedom
(OIF)/Operation
New Dawn
(OND) Veterans
38 U.S.C.
Section 1720(g)
Not
implemented by
VA
TBI: Use of
non-Department
facilities for
rehabilitation
Page 110
Title and
Statutory
Authorities
Nature of
Provision
Eligibility Criteria
Beneficiary
38 U.S.C.
Section 1710E
Not
implemented by
VA
Appropriate
Care for
Gender-Specific
Disabilities of
Women
Veterans
Description
Contract
N/A
Women Veterans
Contract
N/A
Veterans
Contract
N/A
PL 98-160, as
amended by PL
102-40 and PL
102-83
Counseling and
treatment for
Military Sexual
Trauma (MST)
38 U.S.C.
Section 1720D
Readjustment
and Mental
Health Services
for OEF/OIF
Veterans
PL 111-163
304, as
amended by PL
112-239
Page 111
Title and
Statutory
Authorities
Substance Use
Disorder
Treatment
Nature of
Provision
Description
Eligibility Criteria
Beneficiary
Contract
Permits VA through
contract or fee-for-service
payments to provide a
range of services for
substance use disorder
treatment.
N/A
N/A
Contract
N/A
Certain Veterans
Contract
N/A
N/A
Contract
Veterans suffering
from serious
mental illness and
homeless
Veterans
Contract
and other
Authority to procure
prosthetic appliances and
services by purchase,
manufacture, contract, or
any other manner.
N/A
N/A
PL 110-387
103
Native Hawaiian
Health Care
Systems
PL 113-146
103
Contract for
Scarce medical
specialist
services
38 U.S.C.
Section 7409
Health Care for
Homeless
Veterans
38 U.S.C.
Section 2031
Procurement of
Prosthetic
Appliances
38 U.S.C.
Section 8123
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Title and
Statutory
Authorities
Nature of
Provision
Care and
Contract
treatment of U.S. and grant
Veterans by the
Veterans
Memorial Medical
Center
(Philippines)
Description
VA is no longer contracting
with the Veterans Memorial
Medical Center; however,
VA does provide grants for
medical equipment.
38 U.S.C.
Section 1732
Page 113
Eligibility Criteria
N/A
Beneficiary
N/A
8.0
8.1
Appendix
Glossary61
61Definitions
in glossary are drawn from VA internal sources, medical dictionaries, and institutions
containing industry standard definitions. These include CMS, The Farlex Medical Dictionary for Health
Professions and Nursing, and the McGraw-Hill Concise Dictionary of Modern Medicine.
Page 114
Page 115
8.2
Acronym List
Page 116
Page 117
8.3
The plan will consolidate existing authorities and mechanisms for delivering community
care into a single program, the New VCP, simplifying the process for Veterans,
providers, and VA staff (Element 1: Single Program for non-Department Care Delivery
and Element 2: Patient Eligibility Requirements).
Recommendation 2 OPERATIONS: Develop a patient-centered operations model that balances local autonomy with appropriate
standardization and employs best practices for high-quality health care
The New VCP proposes revised processes for Authorizations (Element 3), Claims
Management (Element 5), and Medical Records Management (Chapter 9).
Care coordination should improve health outcomes, prevent gaps caused by transition of
setting or time, and support a positive and engaging patient experience (Introduction:
Care Coordination).
Recommendation 3 DATA and TOOLS: Develop and deploy a standardized and common set of data and tools for transparency,
learning, and evidence-based decision.
Implement a single, integrated set of
system-wide tools centered on a
common EHR that is interoperable
across VHA and with DoD and
community provider systems.
The New VCP proposes medical records management to increase electronic transfer of
relevant medical records between VA, Core Network, including DoD, and community
providers, improving the consistency, simplicity, and timeliness of the information
exchange (Element 9: Medical Records Management).
Assessment A. Demographics
Shifting to a single community care program will give VA greater flexibility in identifying
and responding to access issues (Element 1: Single Program for non-Department Care
Delivery).
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Independent Assessment
Recommendation
This report provides Congress with VAs proposal for a clear strategy and direction for
community care, including required legislative authorities (Element 1: Single Program for
non-Department Care Delivery).
The New VCP proposes approaches for High-Performing Network Development,
including analytics, that are adaptable over time and can adjust to meet the needs of a
changing Veteran population, providing them with access to a tiered network (Element 8:
Plans to Use Current Non-Department Provider Networks and Infrastructure).
VA will designate a new DUSH to establish national management of and accountability
for community care and integration with VA provided care (Element 1: Single Program
for non-Department Care Delivery).
Similarly, at the local level, the New VCP will also standardize community care within
facilities to support consistent management (Element 1: Single Program for
non-Department Care Delivery).
This report includes a transition plan with change management and training necessary to
streamline existing programs and implement improved processes (Element 10:
Transition Plan).
By developing a High-Performance Network, VA plans to implement standards that
improve data sharing, monitoring, and care coordination (Chapter 6: Plan to Develop
Provider Eligibility Requirements and Element 9 Medical Records Management).
VA will identify top performers, measure provider productivity, and develop incentives
such as value-based payments (Element 6: Plan to Develop Provider Eligibility
Requirements and Element 9 Medical Records Management).
The New VCP proposes consistent reimbursement rates tied to regional Medicare.
Rates recommendations include exceptions for specific underserved geographic areas
(e.g., Alaska, Hawaii, Guam, Puerto Rico, American Samoa, and the Commonwealth of
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Independent Assessment
Recommendation
the Northern Marianna Islands); negotiated rates for services not covered by Medicare
rather than VA paying billed charges (Element 5: Provider Reimbursement Rates).
The New VCP will strengthen existing relationships with DoD, IHS, Tribal, and FQHC
partners (Element 5: Provider Reimbursement Rates).
Over time, the New VCP will evolve to include innovative practices from industry for
purchasing care, such as shifts to bundled or value-based payments (Element 1: Single
Program for non-Department Care Delivery).
The New VCP proposes to eliminate inconsistencies between various purchased care
mechanisms by establishment of a single program (Element 1: Single Program for
non-Department Care Delivery).
The New VCP will be flexible to provide access to care through a high-performing
network as demand changes (Element 8: Plans to Use Current Non-Department
Provider Networks and Infrastructure).
Services provided in the network will be complementary to internal VA health care
delivery (Element 8: Plans to Use Current Non-Department Provider Networks and
Infrastructure).
Enhancing the mobile apps portfolio to support the future state continuum of care
coordination, including aspects of patient navigation, secure messaging and mobile Blue
Button (Introduction: Care Coordination).
VA will pursue a claims solution and simplified processes as it evolves to achieve parity
with best practices, working toward consistent, timely payment (Element 4: Billing and
Reimbursement).
The New VCP develops a single, streamlined billing and reimbursement process to
support the program (Chapter 1: Single Program for non-Department Care Delivery).
VA will standardize business rules and processes under a uniform system (Element 10:
Transition Plan).
The transition plan lays out the key elements of the change management plan necessary
to communicate changes in community care programs and processes to all stakeholders
(Element 10: Transition Plan).
Under the New VCP, VA will pursue a claims system that employs best practices,
standardized business rules, and auto adjudication, that will help it ensure compliance
with the Prompt Payment Act (Element 4: Billing and Reimbursement and Chapter 7:
Prompt Pay Compliance).
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Independent Assessment
Recommendation
VHA: Align performance measures to
those used by industry, giving VHA
leadership meaningful comparisons of
performance to the private sector.
VHA: Simplify the rules, policies, and
regulations governing revenue, non-VA
Care, eligibility, priority groups, and
service connections, educate all
stakeholders, and institute effective
change management.
VA will adopt clinical and administrative best practices under the New VCP using data on
Veterans needs and the quality of providers that will allow for parity inside and outside
of VA (Element 1: Single Program for non-Department Care Delivery).
The New VCP defines a single set of eligibility requirements for the circumstances under
which Veterans may choose to receive health benefits from community providers,
enabling timely and convenient access to care in alignment with best practices (Element
2: Patient Eligibility Requirements).
The New VCP will also include plans to communicate these changes to stakeholders
(Element 2: Patient Eligibility Requirements).
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